DENT AL & ME DIC AL HIST ORY
Patient Name: ____________________________________________ Date: _______________________
DENTAL HISTORY
Have you experienced any of the fol owing (please check al that apply):
Rate your smile from 1 – 10: ____________ What would you change: _______________________________________ Does dental treatment make you nervous? Yes No Are you happy with past treatment? Yes No Have you ever had a negative experience in a dental office? Yes No Please explain: ________________________________________________________________________________________ Do you usual y have anesthesia with your dental treatment? ___________________________________________________ Have you had orthodontic work in the past? _____________________________________________ Dates: _____________ Have you had periodontal surgery? __________________________________________________ Dates: _______________ How long since you’ve seen a dentist? __________________________________________ Were X-Rays taken? Yes No What was done at your last dental visit? ____________________________________________________________________ Have you lost any teeth? Yes No If so, why? _______________________________ Were they replaced? Yes No How often do you brush? __________ Floss? __________ What type of toothbrush do you use? Soft Medium Hard MEDICAL HISTORY
Do you have or have you had any of the fol owing conditions (please check al that apply): Anemia/Blood Disorder
Heart Disease/Attack/Surgery Heart Stent
Sore/Enlarged Lymph Nodes Psychosis
Slow Healing Mouth Sores Unintentional Weight Gain or Loss
Other Conditions:_____________________________
Recurrent Il nesses: _______________________________________________________________________________________
MEDICATION INFORMATION
Are you taking any of these medications (please check al that apply): Pre-medications for dental treatment
Tagament (cimetidine) or Prilosec (omeprazole)
Cardizem (diltiazem) or Calan, Isoptin (verapamil)
Diflucan (fluconazole) or Sporonox (itraconazole)
Have you been treated with Bisphosphonate drugs (Fosamax, Aredia, Zometa, Actonel, Boniva)? Yes No
If so, when did treatment begin: ________________________ End: ___________________________ Have you ever taken any prescription drugs such as fen-phen for weight loss? Yes No
Do you consume grapefruit juice, grapefruits or grapefruit extract? Yes No
64 North Main Street • Brockport, NY 14420 office585.637.6884fax585.637.7087emailinfo@brockportsmiles.comwww.brockportsmiles.com DENT MEDIC AL HISTORY DENT AL & ME DIC AL HIST ORY DENT AL & ME DIC AL HIST ORY
Patient Name: ____________________________________________ Date: _______________________
MEDICAL HISTORY CONTINUED Physician Name: _______________________________________________ Phone #: ______________________________ Date of last health care exam: __________________ Do you have any drug al ergies? _____________________________ Have you been hospitalized in the last 5 years? Yes No If yes, reason: _____________________________________ Are you currently receiving care? Yes No If yes, nature of care: __________________________________________ Please list the names and phone numbers of the physicians what are currently providing you care: Name: _____________________________________________ Phone: _________________________________________ Name: _____________________________________________ Phone: _________________________________________ Name: _____________________________________________ Phone: _________________________________________ Please list al medications (prescription or non-prescription) that you are currently taking and reason for medication: Medication: _________________________________________ Reason: _________________________________________ Medication: _________________________________________ Reason: _________________________________________ Medication: _________________________________________ Reason: _________________________________________ Medication: _________________________________________ Reason: _________________________________________ Medication: _________________________________________ Reason: _________________________________________ Medication: _________________________________________ Reason: _________________________________________ Do you have any known al ergies (latex, etc.)? _______________________________________________________________ Other known al ergies? (i.e. pol en, etc.) ____________________________________________________________________ Do you drink: public water wel water bottled water Women: Are you pregnant? Yes No Nursing? Yes No Taking birth control pil s? Yes No Patient or Legal Guardian Signature: _____________________________________________________ 64 North Main Street • Brockport, NY 14420 office585.637.6884fax585.637.7087emailinfo@brockportsmiles.comwww.brockportsmiles.com
Products, technologies and services for the restoration of monuments MINERAL FORMULATION FOR THE REPAIR AND REPRODUCTION OF SANDSTONES Description The formulations of SPARTYTE AR-rap are composed out of special inorganic and mineral components, which, when mixed with ADHEWAT/RM, can be used to repair and reproduce almost every type of sandstone. The product is
Original Article Oral Ciprofloxacin Compared with Intravenous Ceftazidim on Low Risk Febrile Neutropenia in Acute Lymphocytic Leukemia Hashemi A1, Najafi N2, Behnaz F3, Zare A4 1- Department of Pediatrics, Hematology, Oncology and Genetics Research Center, Shahid Sadoughi University of Medical Sciences and Health Services, Yazd, Iran 2- General Practitioner, Yazd, Iran 3- Dep
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DENT MEDIC AL HISTORY