Randy T. Lee, DDS
PATIENT MEDICAL HISTORY
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Patient Name: _____________________

Primary Medical Doctor: __________________________

Address: __________________________________________________
                               Street          Suite.#         City            State          Zip Code

Phone #: _________________________

Date and purpose of last visit to your Medical Doctor: _____________________

Please list your medications and their dosages:

 

Please list any allergies to medication:

Please list any hospitalizations or operations and their dates:

Are you or have you ever had? (Please circle Yes or No for each item)

Ulcers	Yes      No
Pregnant	Yes      No	Smoke	Yes      No	High blood pressure	Yes      No
Heart murmur	Yes      No	Seizures	Yes      No	Heart problems	Yes      No
Immunocompromised	Yes      No	Fainting spells	Yes      No	Heart murmur	Yes      No
Bleeding problems	Yes      No	Cancer	Yes      No	Stroke	Yes      No
Radiation treatment	Yes      No	Diabetes	Yes      No	Kidney disease	Yes      No
Thyroid disease	Yes      No	Asthma	Yes      No	Bone or joint implants	Yes      No
Chest Pains	Yes      No	Eye Disease	Yes      No	Heart failure	Yes      No

DENTAL HISTORY

Last Dentist________________________ Date of last visit _________________

Address __________________________________________________________
                                                   Street            Suite #              City          State                    Zip Code

Date of last X-rays: _____________________________

Have you had problems with past dental visits? ___________________________

Are experiencing any discomfort, pain or sensitivity? ________________________

Please list any orthodontic treatment, periodontal (gum) treatment, endodontic treatment, or jaw joint treatment that you have undergone:

Treatment        Treatment Date

 

 

Patient signature: _________________________ Date: __________