Health History Questionnaire

Welcome to The Polished Tooth Dental Hygiene Center
Date: _________________
Patient Information
To assist the dental hygienist and ensure your well-being during treatment in our office, please
answer the following questions in detail. Thank you
Please print clearly
Name:_____________________________________________________________ Date of Birth: ____/____/____
(First) (Initial) (Last)
Address: _____________________________________________________________________________________________________
(Number) (Apt) (Street) (Town) (Prov.) (Postal Code)
Home Tel: (_____) _______________ Cell: (____)______________ Work: (____)_______________ Age: _____ M F
Emergency Contact:__________________________________________ Tel: (____)________________
Family Doctor:____________________________ Tel: (____)_________________
Dentist:___________________________________ Tel: (____)_________________
How did you hear about our office? _____________________________ Referred by:_______________________________
Financial Information Method of Payment Cash MasterCard Visa Debit

Employer:___________________ Insurance Company:_______________________ Policy/Group number:_________________
Medical Information (This information will remain strictly confidential) YES NO
Are you/ have you been treated for any medical condition within the past year?
If so, why? _________________________________________________________________________________________

When was your last medical checkup or visit? ___________________
Has there been any change in your general health in the past year?
If yes, please explain. _______________________________________________________________________________
Are you taking any medications, non-prescription drugs or herbal supplements of any kind?
If yes, please list. ___________________________________________________________________________________

____________________________________________________________________________________________________
Do you have any allergies? If you answered yes, please list using the categories below:
Medications ____________________________________________________________________________________
Latex/rubber products _________________________________________________________________________
Other (e.g. hay fever, foods, skin) _______________________________________________________________
Do you have or have you ever had asthma, breathing or lung problems?______________________________
Do you have or have you ever had any heart or blood pressure problems?_____________________________
Do you have or have you ever had a stroke or TIA (ministroke)? ______________________________________
Do you have a prosthetic or artificial joint? __________________________________________________________
Do you have any conditions or therapies that could affect your immune system?
e.g. leukemia, AIDS, HIV infection, radiotherapy, chemotherapy?__________________________________
Have you ever had hepatitis, jaundice or liver disease? _______________________________________________
Do you have a bleeding problem or bleeding disorder? ________________________________________________
Do you smoke? � �
If yes, how many per day? ______ Years smoked ____________
Past smoker?
How many years ago did you quit? ________________
For Women only
Are you pregnant?
Are you using birth control? ___________________________
Do you have or have you ever had any of the following? Please check all that apply:
A.I.D.S. Diabetes H.I.V. Positive

Radiation/chemotherapy
Anemia Drug/alcohol Hodgkin’s Disease Rheumatic/Scarlet
dependence Fever
Angina Pectoris Emphysema Hyper/Hypoglycemia Sickle Cell Anemia
Anorexia nervosa Epilepsy Hypertension Sinus trouble
Artificial Heart valve Glandular disorders Jaundice Stomach problems
Arthritis/ Rheumatism Glaucoma Kidney disease Stroke
Artificial Joints Head/neck injuries Liver disease Thyroid disease
Asthma/ Bronchitis Heart disease/attack Leukemia TIA (mini stroke)
Blood disorders Heart murmur Lung disease Tuberculosis
Bulimia Heart Malignant hypothermia Ulcers
pacemaker/surgery
Cancer Heart rhythm disorder Mental/nervous disorder Venereal disease
Circulation problems Hepatitis A B C Mitral Valve Prolapse Other______________
Congenital heart Herpes Organ Other______________
lesions transplant/implant
Cortisone/steroid High/Low blood Psychiatric disorder NONE
pressure
Dental Information
Date of last dental/dental hygiene visit _____________________________________________________
What care did you receive at the last dental visit? Dental exam Cleaning Fillings Emergency visit
How often do you receive dental treatment or dental hygiene care?___________________________
Have you had radiographs (dental x-rays) in the past two years?Type:______________________ � Yes � No
Have you had any dental problems in the last year with your teeth, gums, jaws, chewing? � Yes � No
Sensitive Teeth Bleeding gums Recession
Mouth sores Calculus/ Tartar build-up Abscess
Jaw Problems Broken teeth/fillings Yellowing of teeth
Loose teeth Bad breath Swelling
Dry mouth Cold sores Sinus Problems
Toothache Sore gums Difficulty
swallowing
Grinding of Accident/ injury to teeth Sore jaw
teeth
_____________________________________________________________________________
In order that we may be sensitive to your needs, please tell us of any unpleasant experiences
you may have had related to oral care. _______________________________________________________
Do you have or have you experienced any of the following?
Are your teeth sensitive to: Cold Sweets Hot Other___________________

Do your gums bleed when you: Floss Brush Never
Please rate how happy you are with your smile ( 1- very unhappy 10- very happy)
1 2 3 4 5 6 7 8 9 10
Do you grind or clench your teeth? � Yes � No

Are you a mouth breather? � Yes � No
General Release/Client Consent
I, the undersigned understand that the information contained in the medical and dental history is important to
treatment. I have completed this form to the best of my knowledge and have not knowingly omitted any data.
I consent to the release of medical information from my medical doctor or other health care provider as required
to Josee Laferriere of The Polished Tooth Dental Hygiene Center of Alexandria ON. I authorize this dental
hygienist to perform assessment procedures as may be required to determine necessary treatment. I understand
that I am responsible to pay for fees associated with my dental hygiene treatment.
Policy: I understand that 24 hours notice is required for any cancellation. Evening and Weekend appointments
are prime appointments and frequent cancellations may remove my eligibility to these appointment times
Client Signature Self Parent/Guardian _________________________________ Date: _______________________
Dental Hygienist’s Signature _________________________________________________ Date: _______________________

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Welcome to The Polished Tooth Dental Hygiene Center

Emergency Contact:__________________________ Tel: ()

Family Doctor:____________ Tel: ()_

Dentist:___________________ Tel: ()_

Financial Information Method of Payment Cash MasterCard Visa Debit

If so, why? _________________________________________________________________________________________

If yes, please list. ___________________________________________________________________________________

A.I.D.S. Diabetes H.I.V. Positive

Are your teeth sensitive to: Cold Sweets Hot Other___________________

Do you grind or clench your teeth? � Yes � No

Client Signature Self Parent/Guardian ___________ Date: _

Dental Hygienist’s Signature ___________________________ Date: _

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