Brockportsmiles.com

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
office 585.637.6884 fax 585.637.7087 email info@brockportsmiles.com www.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
office 585.637.6884 fax 585.637.7087 email info@brockportsmiles.com www.brockportsmiles.com

Source: http://www.brockportsmiles.com/cmsAdmin/uploads/Dental-&-Medical-History.pdf

Microsoft word - spartyte ar - rap.doc

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

ijpho.ssu.ac.ir

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

Copyright ©2018 Sedative Dosing Pdf