Medical & Dental History

Client Information

First name

Last name

Address

Including City

Postal Code

Date of birth

Occupation

Gender/Pronouns

Cell Phone #

Alternative Phone #

Email address

Name & Phone Number of Guardian or Power of Attorney/Director of Care(if applicable)

Seniors or Special Needs or Children

Emergency Contact

Add another emergency contact

How did you hear about Welcome Wellness Dental Hygiene?

Treatment Area (please check that you have adequate space for set-up)

6x10 feet, hard flooring, sink nearby, bathroom available

Insurance Information

Name of Insurance Company

Policy #1

Employer

Plan Member

Members Birthday (leave blank if a patient)

Policy # or Group #

ID # or Personal #

Name of Insurance Company

Policy #2

Employer

Plan Member

Members Birthday (leave blank if a patient)

Policy # or Group #

ID # or Personal #

Dental Information

Main Dental Concerns

Date of Last Cleaning

Date of last dental x-rays

Name of Previous Dental Office

Do you have dental related anxiety?

Are you currently experiencing any of the following?

Tooth pain or discomfort while chewing

Loose, tipped, or shifting teeth

Grinding or clenching teeth

Bleeding/Swollen gums

Broken teeth or fillings

Headaches, earaches, or neck pain

Jaw joint pain

Bad breath

Food getting stuck between teeth

Are you interested in Teeth Whitening?

Do you wear a Nightguard or Sleep Appliance?

Do you wear dentures?

Medical History

The information provided to us will remain confidential and helps us to understand how best to treat you.

Family Physician Name/Phone Number

Are you presently under the care of your physician?

Yes

If Yes, please explain

Have you been hospitalized or had any surgery over the last 5 years?

Yes

If Yes, please explain

If any boxes were checked above, please explain. Is there anything else regarding your medical history that we should be aware of?

Are you currently on any medications?

Yes

If so, list the medication, dosage and associated condition.

Please list any supplements including herbs that you are taking.

I acknowledge that Welcome Wellness Dental Hygiene does not provide x-ray services and that I will seek yearly x-rays with my dentist of choice.

Covid-19 Symptoms and other Communicable Diseases

If you have any of these Covid-19 or other disease symptoms, you must cancel your appointment. Please confirm that you do not have any of these symptoms prior to this first appointment.

Cough or shortness of breath
Fever or chills in the last 24 hours
Loss of taste or smell
Felling unwell or fatigue
Sore throat
Nausea or vomiting
Undiagnosed rash, infection or break in the skin
Communicable infectious disease (flu, cold, measles, chicken pox, or tuberculosis)
Recent exposure to Covid-19, positive case exposure
Recent travel to areas where endemic disease are present
Recent travel out of the country in the last two weeks, without Covid-19 PCR test upon return
Tested positive for Covid-19 in the past 14 days

I confirm that I do not have any Covid-19 symptoms listed above

Client or Guardian Name

Date

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