Lawrencefamilydentistry.com

Denny T. Lawrence II,DDS, PA
DENTAL INFORMATION
Reason for today’s visit: ∫ Emergency ∫ Exam ∫ Scheduled Procedure ∫ ConsultationAre you in any pain? ∫ Yes ∫ No If yes, how long have you been in pain? ________________________________________________Please indicate if you have any of the following problems by checking off the corresponding box:∫ Discomfort, clicking or jaw popping ∫ Blisters/sores in or around the mouth Other: ________________________________________________ Have you ever required pre-medication? ∫ Yes ∫ No ∫ Not Sure Previous dentist: _____________________________ Phone: ______________ Last dental exam: __________Last dental x-rays: _________ How many times per day do you brush? _____________ How many times per day do you floss? ____________ What type of toothbrush bristles do you use? ∫ Soft ∫ Medium ∫ Hard MEDICAL HISTORY
Are you under a physician’s care now? Yes  No If yes, please explain:_______________________ Have you ever been hospitalized or had a major operation? Yes  No If yes, please explain:_______________________ Have you ever had a serious head or neck injury? Yes  No If yes, please explain:_______________________ Are you taking any medications, pills, or drugs? Yes  No If yes, please explain:_______________________ Do you take, or have you taken, Phen-Fen or Redux? Yes  No ________________________________________ Have you ever taken Fosamax, Boniva, Actonel or any other medications containing bisphosphonates? Are you on a special diet? Yes  No Do you use controlled substances? Yes  No Women: Are you
Pregnant/Trying to get pregnant? Yes  No Taking oral contraceptives? Yes  No Are you Allergic to any of the following?∫ Aspirin ∫ Other If other, please explain: ____________________________________________________________________________________ Do you have, or have had, any of the followings? Have you ever had any serious illness not listed above? Yes No If yes, please explain: ___________________________________________________ AUTHORIZATION AND RELEASE
I certify that I have read and understand the above information to the best of my knowledge. The above questions have been accurately answered. I understand that providing incorrect information can be dangerous to my health. I authorize the dentist to release any informa- tion including the diagnosis and records of any treatment or examination rendered to me or my child during the period of such dental care to third party payors and/or health practitioners. I authorize and request my insurance company to pay directly to the dentist or dental group insurance benefits otherwise payable to me. I understand that my dental insurance carrier may pay less than the actual bill for services. I agree to be responsible for payment of all services rendered on my behalf or my dependents.
I have been given the opportunity to receive a copy of the Notice of Privacy Practices for the office of Denny Lawrence. I understand that I have the right to request a copy of this policy at any time.
X _____________________________________________________________ Signature of Patient (or parent/guardian if minor)

Source: http://www.lawrencefamilydentistry.com/MedicalHistory.pdf