Smiles By Glerum
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Karen
Glerum,
D.D.S.
2300 S Congress Ave. Ste 110,
Boynton Beach, FL 33426
(561) 374-8922
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Laser Treatment of Mouth Sores
Porcelain Veneers
Crowns and Bridges
Dysport/Botox treatment of Facial wrinkles
Full Mouth Reconstruction
Cosmetic Fillings
Dental Implants
Teeth Whitening
Periodontal Treatment
Sedation Dentistry
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Occlusion Treatment
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Patient Name:
Do you smoke or use tobacco?
Yes
No
If female:
Are you taking Birth Control Pills?
Yes
No
Are you Pregnant?
Yes
No
Are you Nursing?
Yes
No
Do you have - or have you ever had - any of the following conditions and/or treatments?
(Please check all that apply)
Abnormal Bleeding
Alcohol Abuse
Alzheimers
Anemia
Angina Pectoris
Arthritis/Rheumatism
AIDS/HIV
Heart Murmur
Heart Surgery
Hemophilia
Hepatitis
High Blood Pressure
Jaundice
Jaw Pain
Hepatitis Type
Allergies: (check all that apply)
NO KNOWN
Aspirin
Barbituates (sleeping pills)
Codeine
Dental Anesthesia
Erythromycin
Jewelry / Metals
Artificial Heart Valve
Artificial Joints
Asthma
Back Problems
Blood Disease
Blood Transfusion
Cancer Chemotherapy
Circulatory Problems
Chemical Dependency
Kidney Disease
Liver Disease
Lupus
Mitral Valve Prolapse
Pacemaker
Psychiatric Problems
Rheumatic Fever
Scarlet Fever
Seizures
Iodine
Latex
Penicillin
Sulfa
Tetracycline
Other
Other
Congenital Heart Lesions or Defects
Colitis
Cortisone Treatments
Diabetes
Difficulty Breathing
Drug Abuse
Emphysema
Epilepsy
Fainting or Dizziness
Frequent Headaches
Glaucoma
Heart Attack
Heart Disease
Shingles
Shortness of Breath
Sickle Cell Disease
Sinus Problems
Special Diet
Stroke
Swollen Neck Glands
Thyroid Problems
Tonsillitis
Tuberculosis
UIcers
Venereal Disease
Please list any medications you are currently taking
Are there any other diseases conditions or problems that we should be aware of that is not listed above? If so, Please describe:
Pharmacy Information:
Name of Pharmacy:
Phone Number
Location
Emergency Contact
Relationship:
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Patient Signature:
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