New Client Age 16+ Medical & Dental Form

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Welcome to Heritage Dental Hygiene!

For ages 16 years and older please complete this medical & dental history form before your appointment.

First

Last Name

Email

Phone

Address

Emergency contact name, relationship and phone number

How did you hear about our office?

Name of your primary Medical Doctor +phone number and address

When was your last examination/blood work appointment with your Medical Doctor?

Name of any medical specialists that you are treated by:

List any medical condition you have been diagnosed with or are being treated for:

Have you been diagnosed wih Hepatitis A, B or C or HIV Aids?

Yes

No

List any medication prescribed or over the counter that you are taking?

Upload Medication List

Upload supported file (Max 15MB)

Have you been diagnosed with a cardiac (heart) condition or any condition that requires antibiotic prophylaxsis befoe dental treatment. Such as a prosthetic heart valve, heart transplant with abnormal heart valve fnction, congenital heart defects or joint replacement. If yes please list.

Have you had a knee, hip or joint replacement and if so which joint and what year did you have the replacement?

Are you allergic to any medications, foods, drugs, metals or latex? If yes please list your allergies.

Please list any herbal remedies and vitamins that you are taking along with the dose and reason why you are taking them?

Have you been diagnosed with diabetes?

Yes

No

Type 1

Type 2

Pre Diabetic

Do you smoke tobacco cigarettes?

What dental conditions or concerns do you have?

When were your last dental radiographs taken?

How many times a year do you have your teeth cleaned?

3

4

2

1

It has been over a year since my last cleaning

Do you have a dry mouth?

Yes

No

Do you have dental implants? If yes tell us about your dental implant

Would you like to have whiter teeth?

Yes

No

The toothbrush I use most is

Manual

Medium Manual

Sonicare Electric

Oral B Electric

Battery Operated Electric

How often do you floss?

Yes! every day

A few times a week

If food is stuck

Never

Do you use mouthwash?

Yes

No

On occasion

I accept the Heritage Dental Hygiene O/A Amie Banting Dental Hygiene Professional Corporation Privacy Act Policy.View terms of use

Please add any information that I should know that will help me service you better!

Submit Any Additional Records Here!

Upload supported file (Max 15MB)

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Welcome to Heritage Dental Hygiene!

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For ages 16 years and older please complete this medical & dental history form before your appointment.