Randy T. Lee, DDS
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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


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: __________