Surname_________________________________ First Name __________________________ Initial__________ Date of Birth (DD/MM/YYYY) ______________________ Sex M □ F □
Address ____________________________________________________________________ Apt # __________ City __________________________________ Province ____________________ Postal Code _______________ Home Phone# (_____)-______________ Cell# (______)_______________ Business# (______)______________ Occupation___________________________ Email__________________________________________________ IN CASE OF EMERGENCY NOTIFY: NAME__________________________________________________ RELATIONSHIP_____________________________________PH# (_____)_____________________________ Date of Last Medical Visit _____________________ Reason for Visit____________________________________ HEALTH HISTORY – If YES, please describe
Are you currently in the care of a physician?
Has there been any change in your general health in the past year?
Are you now being treated for any medical condition or have you been treated within the past two years?
Have you ever had a serious illness, operation, or been hospitalized?
Are you currently taking any medications including prescription, over the counter or herbal? If YES, please fill out
(Women only) Are you pregnant? YES □ NO □ Due Date __________________________
Are you taking birth control? YES □ NO □
MEDICATION FREQUENCY Do you have or have you ever had any of the Have you ever had any UNUSUAL reaction to following? Y N any of the following? – If YES, please describe DENTAL HISTORY – If YES, please describe
Do you have problems with your jaw? (pain, limited opening, locking, popping)
Are there any growths or sore spots in your mouth?
Have you noticed any changes in your teeth in the last 5 years, become shorter, thinner, or worn?
Do you clench or grind your teeth in the daytime or at night?
Have you ever been diagnosed with periodontal disease?
Do you ever have a dry or burning mouth?
Are you anxious of dental treatment? On a scale of 1-10 ______
Have you ever been advised to take antibiotics prior to a dental treatment?
Have you ever been disappointed with the appearance of previous dental work?
Why did you leave your previous dentist?
Do you have any current dental concerns?
How did you hear about our practice? ________________________ Who can we thank for your referral? ___________________ When was your last dental visit? __________________________ What was it for? _____________________________________ What can we do to make your visit more comfortable? ___________________________________________________________
I HEREBY CERTIFY THAT THIS MEDICAL HISTORY IS ACCURATE AND COMPLETE TO THE BEST OF MY KNOWLEDGE. I CONSENT TO THE PERFORMING OF THE DENTAL PROCEDURES AGREED TO BE NECESSARY OR ADVISABLE, INCLUDING THE USE OF LOCAL ANESTHTIC (FREEZING) OR ANY DRUGS INDICATED.
ZEGERID OTC™ Hits Store Shelves; Offers Only Patented Dual-Ingredient Option for 24 Hour Frequent Heartburn Relief without a Prescription WHITEHOUSE STATION, NJ, April 1, 2010 – Merck & Co., Inc. announced that beginning today, ZEGERID OTC™ (omeprazole 20 mg/sodium bicarbonate 1100 mg capsules), a new over-the-counter (OTC) option for treating frequent heartburn without a pre
Akne vulgaris (AV) adalah penyakit inflamasi kronis pada folikel pilosebasea yang biasanya terjadi pada dewasa muda. Penyebabnya belum diketahui dengan pasti dan dapat disebabkan oleh banyak faktor. Karakteristik penderita AV beragam, dilihat dari usia, jenis kelamin, jenis lesi, dan predileksi. Jenis penatalaksanaannya terdiri dari pengobatan lokal, sistemik, dan fisik. Tujuan penelitian ini ada