Medical & Dental History

Medical & Dental History

PURE Dental Hygiene Care/Simply Dental Hygiene & Wellness
Personal Information
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Birth Date*

MonthDayYear
What is your sex?*
This field may be used for submitting claims to your insurance provider. Please ensure the sex you provide here matches what your insurance provider has on file or what is indicated on your medical record.
Contact Number*
Email
example@example.com
Preferred Method of Contact*

TextEmailPhoneOther
Emergency Contact Information
Name*

First NameLast Name
Contact Number
Relationship*
Health Care Providers
Do you have a dentist?*
Dentist name

First NameLast Name
Do you have a family doctor? *
Doctor's name

PrefixFirst NameLast Name
Dental Insurance Information
Do you have dental insurance?*
If you do not have insurance then please skip this section and move forward to your "Medical Information" below.
If yes, name of insurance company
Policy number (group#)
Subscriber number (certificate #)
Policy holder's Name

First NameLast Name
Policy holder's birth date

MonthDayYear
If you have secondary coverage (dual insurance---through a spouse/partner) please provide their information below
Policy holders name
Relationship
Name of insurance company
Policy number (group #)
Subscriber number (certificate #)
Policy holder's birth date

MonthDayYear
If you prefer we take assignment from your insurance company (we wait for payment so you do not have to pay upfront)---please read and sign below:
Permission Electronic Claims Submission

I authorize release, to my benefits plan administrator and CDHA/CDA information contained in claims submitted electronically. I also authorize the communication of information related to the coverage of services described to the named Dental Hygienists: Angela Murphy, RDH. Lee French RDH

This authorization shall continue in effect until the undersigned revokes the same.
Date

MonthDayYear
Date
Signature

Clear
Agreement for Assignment of Benefits

I hereby assign my benefits, payable from claims submitted electronically, to Angela Murphy, RDH at PURE Dental Hygiene Care OR Lee French at Simply Dental Hygiene & Wellness.

This authorization shall continue in effect until the undersigned revokes the same.
Date

MonthDayYear
Date
Signature

Clear
Medical Information
Are you being treated for any medical conditions?*
*include conditions you are addressing with medications
If yes, please explain
e.g. high blood pressure, diabetes etc
When was your last medical check-up OR phone contact with your doctor/NP?*
(MM-YYYY)
Has there been any changes 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 names and dosage
Do you have any allergies?*
Medications. Foods. Environmental. Hay-fever etc
If yes, please list below
Have you ever had a peculiar or adverse reaction to any medicines or injections*
If yes, please explain reaction
Do you have or have you ever had asthma?*
If yes, what type of puffer do you use and how often?
Do you have or have you ever had any heart or blood pressure problems?*
If yes, please explain
(e.g. high/low blood pressure, heart condition)
Do you have or have you ever had a replacement or repair of a heart valve or an infection of the heart?*
i.e. infective endocarditis, heart condition from birth or a heart transplant
Have you ever had hepatitis, jaundice or liver disease? *
Do you have a prosthetic or artificial joint?*
Date joint(s)were placed
MM-DD-YYYY
Do you have a bleeding problem or bleeding disorder? *
i.e. if you cut yourself does it take longer than 5 minutes to stop bleeding? Any blood clotting disorders?
Have you ever been hospitalized for any illnesses or operations? *
In last 3-5 years?
If yes, please explain: (date and type of operation in last 3-5 years)
Do you have any conditions or therapies that could affect your immune system?*
e.g. leukemia, AIDS, HIV infection, radiation or chemotherapy
If yes, please explain
i.e. chemo/radiation--why did you receive, for how long and when was it completed?
Do you have any of the following? Please click on all those that apply.*

AlzheimersAnginaArthritisAnemiaBlood TransfusionCancerChest PainCold SoresDiabetesAlcohol or drug dependencyEmphysemaEpilepsy or seizuresFibromyalgiaHead or neck injuryHeart attackHeart murmurHigh blood pressureLow blood pressureHodgkins DiseaseHyperglycemiaHypoglycemiaKidney diseaseLung diseaseLupusMigrainesMitral valve prolapseOsteoporosis medicationsPacemakerParkinsons diseaseChemotherapyRadiationRheumatic feverSexually transmitted infection or diseaseShortness of breathSteroid therapyStomach ulcerStrokeThrushThyroid diseaseTMJ (jaw) disorderTuberculosisNONE of the above
Any conditions or diseases not listed above that you have or have ever had?*
If yes, please explain
Are there any diseases or medical problems that run in your family? *
If yes, please explain
e.g. diabetes, heart disease, cancer etc
Do you or did you smoke or chew tobacco products? *
If so, how much? OR when did you quit?
Are you pregnant?
If yes, when is your due date?

MonthDayYear
Date
Are you breastfeeding?
Do you take birth control pills?
Dental History
How would you rate your current dental health?*
What are your present dental concerns, if any. Please select all that apply*

Loose teethBleeding gumsReceding gums/recessionPeriodontal disease/pocketsSensitive teethMissing teeth/spacesCrooked teethTooth achePain with chewingBad breathDry mouthDiscolored teethFood trappingLoose denturesSore/aching jaw jointsNONE of the above
If you have any dental concerns not listed above, please explain here
Do you have any emotional concerns regarding your dental visit? If yes, please check all those that apply*

No emotional concerns with dental treatmentFearPainTimeMoneyEmbarrassmentOther
Please discuss any of your emotional concerns so we can better treat you with care and consideration
When did you last see a dentist for a check-up?*
MM-YYYY
When was your last dental cleaning?*
MM-YYYY
When were your last dental x-rays?*
MM-YYYY
How often do you brush your teeth?*
How often do you clean between your teeth?*
Please click on the items you use for your dental homecare routine

Electric toothbrushManual toothbrushHand flossFloss SticksWaterflosserOther
Have you ever been advised by a medical or dental professional to take antibiotics before your dental appointments?*
e.g. due to joint replacement or heart condition etc
Have you ever experienced any blows to your jaw or face?*
If yes, please explain
Have you noticed any problems with your jaw joint? Please check all those that apply*

No issues noticed with jaw jointPainSoundsLimited openingClicking or poppingDifficulty with chewingOther
Please explain any issues noted above with jaw joint
Do you clinch or grind your teeth OR have you ever been told by a dental professional that you clinch or grind?*
Have you ever had any implant surgery in your jaw or either jaw joints?*
If yes, when was the surgery completed and who performed?
Are you happy with appearance of your teeth?*
If unhappy, what would you like to change about your smile?
Please discuss anything of concern with your past dental history or any present concerns you would like addressed below.
Consent for Treatment & Privacy Policy

I, the undersigned, certify that I have provided an accurate and complete personal and medical & dental history. I have not knowingly omitted any information. I have had the opportunity to ask questions and receive answers regarding this medical & dental history. Should there be any change in either my health status or any other information I have provided, I will advise the dental hygienist.

I authorize the provider (dental hygienist) to perform dental hygiene diagnostic procedures as may be required to determine necessary treatment and the authorization to proceed with that determined treatment. I understand this action will give my consent verbally.

I acknowledge and understand that despite recommendations that encryption software be used as a security mechanism for electronic communications, it is possible that communications with the dental hygienist, or dental information provided from or to my medical doctor, dentist or other health care provided as needed, may not be encrypted. Despite this, I agree to communicate with the dental hygienist and give my permission to the dental hygienist to correspond through a phone call, text message or email communication if necessary with myself or a dentist/doctor/health care provider with a full understanding of the risk.

I have had the opportunity to ask questions and have been advised of the privacy policy of the office and that my personal information will be collected, used and disclosed within the guidelines of the policy. This policy can be accessed at: puredentalhygienecare.com
Patient Name*
Date*

MonthDayYear
Signature

Clear
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