Medical Update Form - Henley Dental

Patient Name*

First Last

Nickname/Preferred Name:

Date Of Birth:*

Primary Phone Number:*

This is a:*

Home Phone
Cell Phone

Please Note: Our office uses text message reminders that can only be sent to cell phones. If you do not use a cell phone. We can send reminders via email.

Secondary Phone Number:

This Is A:

Home Phone
Cell Phone

Email Address:*

Home Address / Mailing Address:*

Street Address Address Line 2 City Province Postal Code

Doctor's Name Specialty

What is your estimate of your general health?*

Excellent
Good
Fair
Poor

Have you ever been hospitalized for an illness or injury?*

Yes
No

If yes, reason for hospitalization and estimated date:

Have you ever had an allergic or bad reaction to the following (please check):

DO YOU HAVE or HAVE YOU HAD (please check if applicable):

Please provide more details:

ARE YOU:

Presently being treated for any other illness?
Taking dietary supplements?
Often exhausted or fatigued
Experiencing frequent headaches
A smoker, smoked previously or use vapes
Taking birth control
Currently pregnant
Currently breast feeding

Please provide more information:

Please list any current medical treatment, impending surgery, genetic/development delay, or other treatment that may possibly affect your dental treatment:

List all medications, supplements or vitamins being taken (Include drug name, dosage, and purpose for taking it):

Dental History

Previous Dentist's Name:

Doctor's Name

Previous Dentist's Phone Number:

How Long Were You A Patient?

Do you have any specific dental concerns (please list):

When Was Your Last Dental Appointment (Estimate If Necessary)?

I routinely see my dentist every:

On a scale of 1 to 10, how fearful of dental treatment are you, where 1 is not fearful and 10 is very fearful:

Have you had an unfavourable dental experience?

Yes
No

Have you ever had complications from past dental treatment?

Yes
No

Have you ever had any trouble getting numb or had any reactions to local anesthesia?

Yes
No

Did you ever have braces, orthodontic treatment or had your bite adjusted?

Yes
No

Have you had any teeth removed, missing teeth that never developed or lost teeth due to injury or facial trauma?

Yes
No

Gum And Bone

Do your gums bleed sometimes or are they ever painful when brushing or flossing?

Yes
No

Have you ever been treated for gum disease or been told you have lost bone around your teeth?

Yes
No

Have you ever noticed an unpleasant taste or odor in your mouth?

Yes
No

Is there anyone with a history of periodontal disease in your family?

Yes
No

Have you ever experienced gum recession, or can you see more of the roots of your teeth?

Yes
No

Have you ever had any teeth become loose on their own (without an injury), or do you have difficulty eating an apple?

Yes
No

Have you ever experienced a burning or painful sensation in your mouth not related to your teeth?

Yes
No

Tooth Structure

Have you ever had any cavaties within the last 3 years?

Yes
No

Does the amount of saliva in your mouth seem too little or do you have difficulty swallowing any food?

Yes
No

Do you feel or notice any holes (ie. craters) on the biting surface of your teeth?

Yes
No

Are any teeth sensitive to hot, cold, biting, sweets or do you avoid brushing any part of your mouth?

Yes
No

Do you have any grooves or notches on your teeth near the gum line?

Yes
No

Have you ever chipped teeth, broken teeth or had a cracked filling?

Yes
No

Do you frequently get food trapped between any teeth?

Yes
No

Bite And Jaw Joint

Do you have problems with your jaw joint? (pain, sounds, limited opening, locking, popping)

Yes
No

Do you clench or grind your teeth during the day?

Yes
No

Do you have any problems with sleep (i.e. restlessness or teeth grinding), wake up with a headache or an awareness of your teeth?

Yes
No

Do you wear or have you ever worn a bite appliance or night guard?

Yes
No

Smile Characteristics

Is there anything about the appearance of your mouth (smile, lips, teeth, gums) that you would like to change (shape, color, size, display)? If so please explain:

Have you ever whitened your teeth?

Yes
No

Have you felt uncomfortable or self conscious about the appearance of your teeth?

Yes
No

Have you been disappointed with the appearance of previous dental work?

Yes
No

Date*

Name

First Last

Signature*