Pageflex server [document: a2266081_00001]
Maplewood Oral and Maxillofacial Surgery, P.A.
Patient Name ____________________________________________________ Date of Birth _________________ M □ F □
Dentist __________________________________________ Orthodontist (if applicable) _____________________________________
And Relationship _________________________________________________________ Phone_____________________________If patient is a minor and parents are divorced, which parent has legal custody?
___Mother ___Father ___Joint*
*If Joint custody both parents must give consent for treatment per MN State Law.
What is the purpose of your visit? ________________________________________________________________________________
If applicable, please complete the following:
Chewing or Swallowing?
Have you received previous treatment for this problem? □ No □ Yes If yes, please complete the following:
□ Surgery ___________________________________________________________________________________________________
□ Medications _______________________________________________________________________________________________
□ Other ____________________________________________________________________________________________________
(list conditions pertinent to this problem) _____________________________________________________________
Tobacco Use ____________________ Alcohol Use _____________________ Occupation ____________________
REVIEW OF SYSTEMS
Pertinent Medical Questions
Is a physician currently treating you for any condition?
□ Name of Physician __________________________
Are you currently taking any prescription, over-the-counter, or
Physician’s Phone Number ____________________
herbal medications or any supplements? (If yes, please list in box at right) □
Name & Dose of Medications and Supplements
Have you ever used marijuana, cocaine, heroine, ecstacy, meth, or
other such drugs? Please list: ____________________________ □
Do you or have you ever taken medications for Osteoporosis or
Osteopenia like Fosamax, Actonel, Boniva, Reclast, etc.? Please
Have you ever had general anesthesia (going to sleep for a
Have you or your immediate family member(s) ever had any
unusual reactions to local anesthetic (Novocaine) or general
Are you aware of any previous reactions or allergies to latex?
Are you allergic to any drugs/medications? (Please Specify)
□ □ ___________________________________________
Pertinent Medical Questions
Do you have chest pains or shortness of breath?
Do you have asthma or any other lung disease?
Have you been diagnosed with sleep apnea?
Do you have a heart murmur?
Do you bleed excessively when you cut yourself or
are you currently taking a blood thinning medication?
Do you have Anemia (thin blood) or any other type
Have you been diagnosed with high blood pressure?
Do you suffer from stomach acid reflux?
Do you have kidney problems?
Are you pregnant (or possibly pregnant)?
Do you have Diabetes (sugar disease)?
Have you ever had x-ray or cobalt treatments for Cancer
Have you received treatment for Cancer? (Please specify)
Do you have Epilepsy or seizures?
Have you ever had back or neck injuries? (Please specify)
Have you ever had jaw joint pain or clicking; TMJ pain?
SYNTHESE DE LA LIDOCAÏNE Lire le protocole suivant extrait du Journal of Chemical Education (Vol 76. No. 11 November 1999). The Preparation of Lidocaine - Thomas J. Reilly Department of Chemistry and Biochemistry, Loyola Marymount University, 7900 Loyola Blvd., Los Angeles, CA 90045-8225; email@example.com This synthesis of 2-(diethylamino)-N-(2,6-dimethyl-phenyl)acetamide, comm
PRESS INFORMATION Development of TEQ Series of Compact Analog Tuners and TMQ Series of Compact Analog Tuner Units with Built-in IF+MPX Thinner Units for LCD and Plasma Televisions ALPS Electric Co., Ltd. (Tokyo, Japan: Masataka Kataoka, President) hasdeveloped two new tuners for use in thin televisions such as LCD and plasmaTVs. The TEQ Series is a compact analog tuner that is 50%