Update Records

Glenbrook Dental | Update Your Records

If you are a current Glenbrook Dental client, feel free to use our convenient online form below to update your existing records with us. We keep your information confidential and will only use it to provide you with the highest quality dental service. Keep your information up to date and ensure your visits are smooth and efficient.

Keep Up To Date

Name*
Email*
Phone*
Address*
Postal Code*
Date of Birth*
Alberta Health Care Number
Previous Dentist?
When was your last dental exam?
When was your last hygiene therapy? (Dental Cleaning)
Have you had x-rays in the last 3 years?
YesNo
Do you have any dental problems or concerns presently?
YesNo
If Yes, please describe
Do you have any pain or soreness around your eyes, ears, or other parts of your face?
YesNo
Does your jaw click or pop when you yawn or eat?
YesNo
Do your jaw muscles ever feel tired?
YesNo
Do you have "tension headaches"?
YesNo
Are you aware of stiff neck muscles?
YesNo
Do you clench your teeth during the day?
YesNo
Are you happy with your smile?
YesNo
Would you like information on:
WhiteningCrownsWhite FillingsDenturesRoot CanalsImplantsCrowns And BridgesGum TreatmentInvisalignOther
Are you interested in invisalign or cosmetic dentistry?
YesNo
Are you being treated for any medical condition at the present or have you been treated in the past?
YesNo
If yes, why and who treated you?
When was your last medical check up?
Have you been hospitalized within the last 2 years?
YesNo
Are you taking any medication, non-prescription drugs or herbal supplements of any kind?
YesNo
If yes, please list, along with dosage and frequency:
Do you have any allergies including medications, latex/rubber products, eggs/food etc?
YesNo
If yes, please list:
Do you have a history of medications which could be immunosuppressive? (ie. chemotherapy)
YesNo
Have you ever had any adverse reaction to dental anaesthetics? (ie. Does it take more/less quantity of anaesthetic or more/less time for the anaesthetic to work for you?)
YesNo
Do you have or have you ever had asthma?
YesNo
Do you have or have you had a replacement or repair of a heart valve?
YesNo
Do you have or have you had an infection of the heart? (eg. Endocarditis)
YesNo
Do you have or have you had a heart condition from birth? (eg. Congenital Heart Disease)
YesNo
Do you have a prosthetic or artificial joint?
YesNo
If yes, what year and which joint?
Do you have any conditions or therapies that could affect your immune system? (eg. Leukemia, AIDS, etc)
YesNo
Have you ever had hepatitis, jaundice or liver disease?
YesNo
Are you taking any anticoagulation (blood thinner) medications?
YesNo
If yes, please list:
Do you have a bleeding problem or bleeding disorder?
YesNo
Do you have or have you had any of the following? (check all that apply)
Chest Pain / AnginaHeart AttackStrokeHeart MurmerDiet Pill TherapyShortness of BreathRheumatic FeverBone or Joint DisordersTuberculosisCancerHigh Blood PressurePacemakerLung DiseaseStomach UlcersArthritisFainting SpellsCorticosteroid TherapyDiabetesThyroid DiseaseDrug/Alcohol DependencySleep Apnea/CPAP MachineEpilepsy/SeizuresKidney DiseaseAnxiety/DepressionOsteoporosis
Are there any diseases or medical problems that run in your family (eg. Diabetes, Cancer, Heart Disease), a history of Prion disease, or symptoms that may be indicative of CJD?
YesNo
If so, which ones?
Do you have a new cough or shortness of breath, new fever or chills in the last 24 hours, new onset of diarrhea, or a new undiagnosed rash, lesion, or break in the skin?
YesNo
If yes, please list
Have you had a recent exposure to communicable infection disease? (ie. measles, chicken pox, tuberculosis)
YesNo
Do you smoke or chew tobacco products?
YesNo
If yes, how much?
Have you had treatment for osteoarthritis with any bisphosphonate medication (eg. Fosamax, Boniva, etc.) for longer than one year?
YesNo
FOR WOMEN ONLY: Are you pregnant or breast feeding?
YesNo
If pregnant, when is your delivery date?

#204 – 3715 51 Street SW 587-483-9900