Patient Medical History Physician______________________________________________ Office Phone___________________________Date of Last Exam_________________ Are you under a physician’s care now? Yes No If yes, please explain:________________________________________________ Have you recently been hospitalized? Yes No If yes, please explain:________________________________________________ Are you taking any medications, pills, or drugs?
Yes No Please list drugs:____________________________________________________ Do you take, or have you taken, Phen-Fen or Redux? Yes No Have you ever taken Fosamax, Boniva, Actonel or any other medications containing bisphosphonates? Yes No Are you on a special diet?
Yes No Do you use tobacco? Yes No Do you use controlled substances? Yes No
Women: Are you: Pregnant/Trying to get pregnant? Yes No Taking oral contraceptives? Yes No Nursing? Yes No Are you allergic to any of the following?
Aspirin Penicillin Codeine Local Anesthetics Acrylic Metal Latex Sulfa drugs Other If yes, please explain:_________________________________________________________________________________________________________________
Do you have, or have you had, any of the following?
Cold Sores/Fever Blisters Yes No Heart Murmur
Congenital Heart Disorder Yes No Heart Pacemaker
Patient Dental History Name of Previous Dentist______________________________________________________________________ Date of Last Exam___________________________ Previous Dentist’s Location____________________________________________________________________ Date of Last Cleaning________________________ Yes No Yes No 1. Do your gums bleed while brushing or flossing?
14. Have you ever had any prolonged bleeding 2. Are your teeth sensitive to hot or cold liquids/foods?
following extractions? 3. Are your teeth sensitive to sweet or sour liquids/foods?
15. Do you wear dentures or partials? 4. Do you feel pain to any of your teeth?
If yes, date of placement____________________________ 5. Do you have any sores or lumps in or near your mouth? 16. Do you have frequent headaches? 6. History of any periodontal therapy? 17. Do you clench or grind your teeth? 7. Do you like your smile? 18. Have you ever experienced any of the following problems 8. Do you snore or have you been told that you snore? in your jaw? 9. Have you ever received oral hygiene instructions? Clicking, popping 10. Have you had any head, neck or jaw injuries?
Pain (joint, ear, side of face) 11. Do you bite your lips or cheeks frequently? Difficulty in opening or closing 12. Have you ever had any difficult extractions in the past? Difficulty in chewing 13. Have you had any orthodontic treatment? To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient’s) health. It is my responsibility to inform the dental office of any changes in medical status. SIGNATURE OF PATIENT, PARENT OR GUARDIAN__________________________________________________________DATE____________________________
Available online at www.sciencedirect.comEstrogen therapy reduces nocturnal periodic limb movementsHelena Hachul , Edmund Chada Baracat , Jos´e Maria Soares Jr. ,Mauro Abi Haidar , Marco T´ulio de Mello ,S´ergio Tufik , Lia Rita Azeredo Bittencourt a Department of Medicine and Sleep Biology, Unifesp - Universidade Federal de S˜ao Paulo, SP, Brazil b Department of Gynecology, Unifes
Cheng HJ et al / Act a Pharmacol Sin 2002 Nov; 23 (11): 1035-1039 2002, Act a Pharmacologica Si nica ISSN 1671-4083 Shanghai Institute of Materia Medica Chinese Academy of Sciences http:/ /www.ChinaPhar.com chronic prostatitis or infertility with chronic prostatitis CHEN Hong-Jie 1 , WANG Zhi-Ping 2 , CHEN Yi-Rong, QIN Da-Shan, FU Sheng-Jun, MA Bao-Liang 1 Now in 1st Renmin Hospital of L