www.lakewoodlaserdentist.com

Patient History
Patient Name :

First Name Middle Name Last Name
Do you have regular medical checkups?

Yes No
Are you under the care of a physician now?

Yes No
Reason :
Have you ever had a serious head injury?

Yes No
Explain :
Have you taken either oral or IV bisphosphonates?

Yes No
Explain :
Are you allergic to any other substances?

Yes No
Explain :
Are you taking any medications/supplements?

Yes No
If yes, please list below
Do you now or have you ever had any of the following?
Heart Disease/ Disorder -

Heart Attack/ Failure Irregular Heart Beat Mitral Valve Prolapse Artificial Heart Valve Heart Surgery/ Stent Angina/ Chest Pain Heart Murmur/ Rheumatic Fever Bacterial Endocarditis Pacemaker/ Defibrillator
Lung Disease/ Disorder -

Tuberculosis Asthma/ Emphysema Persistent Cough Sinus Problem/ Allergy
Reheumatism/ Arthrtis -

Osteoporosis Artificial Joint Cortisone Treatment
Kidney Disease/ Disorder -

Renal Failure/ Dialysis
Cold Sores/ Fever Blisters -

Hives or Rash Venereal Disease/ Genital Herpes HIV Positive/ AIDS
Liver Disease/ Disorder -

Hepatitis A, B, C, Other Diabetes or Family History Excessive Thirst/ Urination
Neurological Disease/ Disorder -

Epilepsy/ Seizures Fainting/ Dizziness
Digestive Disorder/ Reflux -

Ulcers/ Diarrhea Recent Weight Loss/ Gain Colon Disease/ Disorder Thyroid/ Parathyroid Disease
Cancer / Tumors -

Chemotherapy/ Radiation Psychiatric Care Drug Addition/ Alcoholism Alzheimers/ Demetia
Circulatory Disorders -

Stroke Swelling of Limbs Bruise Easily/Anemia Blood Disease Blood Transfusion Bleeding Disorder High/Low Blood Pressure
Do you have any health issues not listed above?
Women - Are you pregnant, think you may be pregnant or currently nursing?

Yes No
Have you ever been told you needed to take antibiotics before a dental procedure?

Yes No
If yes, Why?
*

To the best of my knowledge, all preceding answers are correct. If I have any changes in my health status or medications, I shall inform the dentist and/or staff at the next appointment.

These Questions will help you identify and communicate to us important personal issues with respect to your dental goals.
1. Why are you coming to see us?
2. What is important to you about your teeth?
3. How would you describe the present condition of your mouth?
4. How do you feel about the appearance of your smile?
5. How do you see your teeth 20 years from now?
6. What has kept you from going ahead with the dentistry you want?
7. What quality of dentistry are you looking for?
8. Describe your ideal dental office/ provider
9. What else would you like us to know about you?
Signature: *

(Your digital signature (full name) is as legally binding as a physical signature.) Clear
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Patient History

These Questions will help you identify and communicate to us important personal issues with respect to your dental goals.