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Health History Questionnaire
Confidential
(Mr/Mrs/Ms/Miss)……………………………………………………………………. Date of birth……………………………………… BLOCK LETTERS Address:………………………………………………………………………………………………………………………………………… Home Phone:……………………………………………………………. Work phone:…………………………………………………. Email address:…………………………………………………………… Mobile/Fax:…………………………………………………. Do you want to receive your correspondence by email? Y N Name of referring Dentist?. Name of family Doctor?. How did you hear about us? Yellow pages/White pages/Word of mouth/Referral/Other Do you have Medical Insurance? Y N Name of Company and Policy……………………………………………. Is this consultation accident related? Y N Claim number and date of accident………………………………………. Do you carry a specialist card/bracelet? Y N Please specify………………………………………………………………. What is your weight?. What is your height?. HAVE YOU HAD ANY OF THE FOLLOWING? (CIRCLE Y/N) Heart trouble or heart murmur? What and when? ………………………………………………………………. Y N Rheumatic Fever? What and when? ………………………………………………………………. Y N Jaundice or Hepatitis? What and when? ………………………………………………………………. Y N Diabetes? When? ………………………………………………………………. Y N Asthma? When? ………………………………………………………………. Y N Have you ever had any serious illness? What and when? ………………………………………………………………. Y N ……………………………………………………………………………………………………………………………………. If yes, were you treated in hospital? When?. Have you had any previous operations? What and when? ………………………………………………………………. Y N Have you ever had a full General anaesthetic before? What and when? .………………………………………………. Y N Do you have a history of fainting ………………………………………………………………. Y N Are you taking any pills, tablets or medicine now or in the past 6 months? What and when? ………. ……………………………………………………………………………………………………. Y N Are you currently taking any herbal/natural remedies? Please specify .…………………………………………………. Y N ……………………………………………………………………………………………………………………………………. Are you currently taking WARFRIN, CARTIA or ASPIRIN? Specify how many per day………………………………. Y N Have you ever taken FOSAMAX? Specify when……………………………………………………………………………. Do you use recreation drugs? Specify…………………………………………………………………………………………Y N Are you a smoker? Number per day…………………………………………………………………………………………… HAVE YOU EVER HAD A REACTION TO ANY MEDICINES, INJECTIONS OR STICKING PLASTER?(penicillin or other antibiotic, aspirin, other tables or anaesthetics) please specify ……………………………………………………………………………………………………………………………………. Y N Have you ever had a bad reaction during dental treatment? Specify ……….……………………………………. Y N Have you ever had a bleeding problem? What? ………………………………………………. Y N Are you wearing an artificial or prosthetic joint? Specify type ………………………………………………. Y N Have you any reason to believe that you may be at risk from HIV infection? …………………………………………. Y N Do you believe that you may be at risk from any other disease? …………………………………………. Y N Is there any other health matter your surgeon should know? …………………………………………… Y N FEMALES Are you pregnant? ……………………………………………………………………………………. Y N Are you on the oral contraceptive pill? ……………………………………………………………………………………. Y N Name: (Mr/Mrs/Ms/Miss …………………………………………………………………………………………………… Relationship: i.e Mother/Father ……………………………………………………………………………………………. Address: ……………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………………………… …………………………………………………. Work phone:………………………………. Email address …………………………………………………. Mobile/Fax ………………………………… The medical history I have given is true and correct to my knowledge: Signed: …………………………………………………………. Date: ……………………………………………. To be completed by the parent/guardian/caregiver if patient is UNDER 16 YEARS OF AGE Name: (Mr/Mrs/Ms/Miss …………………………………………………………………………………………………… Signed: ………………………………………………………………… DATE:………………………. Medical update: I have read my Health History and confirm that is adequately states past and present conditions. Date: ………………………………………. Signed: …………………………………………………. Date: ………………………………………. Signed: …………………………………………………. Date: ………………………………………. Signed: ………………………………………………….
FINANCIAL AGREEMENT /TERMS OF TRADE

Please read carefully.
I understand that payment is due at the time of treatment unless other arrangements have been made. By accepting services/treatment at this practice you agree to our terms of trade. I hereby agree inconsideration of credit being extended to me to pay ALL collection costs, court costs & solicitor fees in the event that this account becomes overdue.

Source: http://www.angleseaoms.co.nz/assets/Uploads/Health-Questionnaire/Health-History-Questionnaire.pdf

Microsoft word - mali_120711_sitrep_final pdf.doc

Mali • Complex Emergency Situation Report No. 11 11 July 2012 This report is produced by the OCHA Regional Office for West and Central Africa in Dakar in collaboration with humanitarian partners and is issued by OCHA Headquarters in New York. It covers the period from 27 June to 10 July 2012. The next report will be issued on or around 25 July. I. HIGHLIGHTS/KEY PRIORITIE

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