West Bay Dental (formerly Carey V. Lasley, DDS)1801 West Bay Drive NW, Ste 101A
Olympia, WA 98502
(360) 866-9500
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San Diego Dentist - Balboa Dentistry

Simply complete the form below and someone from our dental team will contact you soon.

Health History Form

Montgomery Plaza Dental

The benefits of a happy, healthy smile are immeasurable! Our goal is to help you reach and maintain maximum
oral health. Please fill out this form completely. The better we communicate, the better we can care for you.


About You

  • Today's Date
  • E-mail Address
  • Full Name (Last, First, Initial)
  • , ,
  • Mr.Mrs.Ms.Dr.
  • I prefer to be called
  • Responsible Party Name (Last, First, Initial)
  • , ,
  • Date of Birth
  • Social Security
  • Marital Status
  • SingleMarriedWidowedSeparatedDivorced
  • Home Adress
  • City, State Zip
  • ,
  • Phone
  • Home-Work-Cell-
  • Driver's License
  • Whom may we thank for referring you?
  • Other family members seen by us
  • Employer
  • How long there?
  • Occupation
  • Employer's Address
  • City, State Zip
  • ,

Emergency Information

  • His/Her Name
  • Relation
  • Phone
  • Home-
  • Work-
  • Address
  • City, State Zip
  • ,

Spouse Information

  • His/Her Name
  • Relation
  • Social Security
  • Date of Birth
  • Employer
  • Driver's License
  • Phone
  • Home-
  • Work-

Dental Insurance Information

Primary Insurance

  • Insurance Co. Name
  • Phone
  • Group #
  • Insurance Co. Address
  • Insured's Name
  • Insured's Social Security #
  • Insured's Birthdate
  • Insured's Employer
  • Employer's Address
  • City, State Zip
  • ,

Medical History

  • Do you have a personal physician?
  • YesNo
  • Physician's Name
  • Phone
  • Date of last visit
  • Your current physical health is
  • FairGoodPoor
  • Are you currently under the care of a physician?
  • YesNo
  • Please explain
  • Are you taking any prescription/over-the-counter drugs?
  • YesNo
  • Please list each one
  • For Women Are you taking birth control pills?
  • YesNo
  • Are you pregnant?
  • YesNo
  • When due:
  • NOTE: Oral antibiotics may interfere with the effectiveness of oral contraceptives. Please consult with your physician.
  • Please check any of the following diseases or medical problems you have ever had.
  • Abnormal BleedingAlchol / Drug Abuse
    AnemiaArthitis
    Artificial/Joints/ValvesAsthma
    Blood TransfusionCancer/Chemotherapy
    Chest PainCongenital Heart Defect
    DiabetesDifficulty Breathing
    EpilepsyExcessive Bleeding
    Fainting SpellsFrequent Headaches
    GlaucomaHIV / AIDS
    Hay FeverHeart Attack/Surgery
    Heart MurmurHemophilia
    Hepatitis, Any FormHerpes / Fever Blisters
    High Blood PressureHospitalized for Any Reason
    Kidney ProblemsLiver Disease
    Low Blood PressureMitral Valve Prolapse
    PacemakerPsychiatric Problems
    Radiation TreatmentRheumatic / Scarlet Fever
    SeizuresSickle Cell Disease / Traits
    Sinus ProblemsStroke
    Thyroid ProblemsTuberculosis (TB)
    UlcersVenereal Disease
  • Please list any serious medical condition(s) that you have ever had
  • I have no prior or existing medical conditions.
  • TrueFalse
  • Are you allergic to any of the following?
  • AspirinCodeineDental Anesthetics
    ErythromycinJewelry/MetalsLatex
    PenicillinTetracyclineOther
  • Please list any other drugs/materials that you are allergic to
  • I have no drug or material allergies.
  • TrueFalse

Dental History

  • Why have you come to the dentist today?
  • Are you currently in pain?
  • YesNo
  • Do you require antibiotics before dental treatment?
  • YesNo
  • Previous dentist
  • Last visit
  • Last cleaning date
  • Last x-ray date
  • Why did you leave your previous dentist?
  • What did you like most & least about any dentist you have seen?
  • Your Current dental health is
  • FairGoodPoor
  • Have you ever had a serious/difficult problem associated with any previous dental work?
  • YesNo

  • How often do you brush?
  • times per day
  • How often do you floss?
  • times per day
  • Do you smoke or use tobacco in any other form?
  • YesNo
  • Are your teeth sensitive to heat, cold or anything else?
  • Do you have loosening of teeth?
  • YesNo
  • Do you still have wisdom teeth?
  • YesNo
  • Do your gums ever bleed?
  • YesNo
  • Have you ever had periodontal disease?
  • YesNo
  • Have you ever had gum treatments?
  • YesNo
  • Does food catch between your teeth?
  • YesNo
  • Do you now or have you ever experienced pain / discomfort in your jaw joint (TMJ / TMD)?
  • YesNo
  • Do you clench or grind your teeth?
  • YesNo
  • Do you have clicking or popping of your jaws?
  • YesNo
  • Would you like fresher breath
  • YesNo
  • Whiter teeth?
  • YesNo
  • Are you happy with the way your smile looks?
  • YesNo
  • If not what whould you change
  • Have you ever tride Nitrous Oxide (relaxing gas)?
  • YesNo
I affirm that the information I have given is correct to the best of my knowledge. It will be held in the strictest confidence and will only be used as stated in this office's Privacy Policy. My signature will serve as my written authorization until I choose to revoke it, in writing. It is my responsibility to inform this office of any changes in my medical status. I authorize the dental staff to perform the necessary dental services I may need.Responsibility for payment for Dental Services provided in this office is that of the patient or responsible party, due and payable at the time services are rendered. I certify that if I am covered by dental insurance, I assign directly to Dr. John S. Rubin all insurance benefits otherwise payable to me. I also understand that if after two months (60 days) my insurance company has not paid the claim or if there is an outstanding balance still due after insurance, then it becomes my responsibility. I authorize the use of my signature on all my insurance submissions to secure the payment of benefits. A 1.50% finance charge (18% annually) will be added to any balance over 60 days due.
  • Enter your name to agree to our Privacy Policy
  • Enter your name to agree to our Payment Policy

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Accessibility: West Bay Dental strives to ensure that its services are accessible to people with disabilities. westbaydentalwa.com has invested a significant amount of resources to help ensure that its website is made easier to use and more accessible for people with disabilities, with the strong belief that every person has the right to live with dignity, equality, comfort and independence.
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