PATIENT INFORMATION Patient’s Full Name__________________________________________ Date of Birth_______________ Age_______ Sex______
Address______________________________________________City/State_________________________Zip Code___________Home Phone_________________________________ SSN_________ ____________ Email_____________________________________
Names of friends or relatives who were former patients___________________________________________________________Who may we thank for referring you to our office? _____________________________________________________________
Patient’s Dentist__________________________________ Patient’s Physician_______________________________________ INSURANCE INFORMATION
Insured’s Name_________________________________ Date of Birth ___________ Insured's Social Security #_______________Insurance Company_____________________________________________ Group #_____________Local #_________________Insurance Company Address_________________________________________________________________________________Insurance Company Phone #______________________________Insured's Employer___________________________________
Insured’s Name_________________________________ Date of Birth___________ Insured's Social Security #_______________Insurance Company_____________________________________________ Group #_____________Local #_________________Insurance Company Address_________________________________________________________________________________Insurance Company Phone #______________________________Insured's Employer___________________________________
DENTAL HISTORY
Does patient receive regular dental checkups? YES NOLast dental exam___________________________________ Last dental x-rays_________________________________________Has patient received any previous orthodontic consultation or treatment?____________________________________________How often does patient brush their teeth?_______________________ Is floss used?_____________ How often?_____________Does the patient currently have, or has the patient ever had any of the fol owing?
Any clicking, popping or pain of jaw, joints (TMJ)
What?_______________________________________________
What are you or your Dentist most concerned about? (Purpose of visit)______________________________________________ ________________________________________________________________________________________________________
CONTINUED ON BACK ---------> ORAL HISTORY
The fol owing are some habits commonly found which may influence tooth position. List info as pertains to patient:
Other habits______________________________________________________________________________________________
Has patient ever had any speech therapy?______________________________________________________________________
List any musical wind instruments played_______________________________________________________________________
HEALTH HISTORY
Has patient been under the care of a physician during the past two years? (other than routine checks)
If yes, what for?___________________________________________________________________________________________Is patient currently taking medications?________________________________________________________________________Is patient al ergic to anything (drugs, food, pol en, etc.)?___________________________________________________________
Does the patient currently have, or has the patient ever had any of the fol owing?Y N Tonsils Removed
Have you been diagnosed or treated for osteoporosis? Y N
If yes, have you ever taken or are you now currently taking:
Fosamax Didronel Boniva Actonel Reclast or a generic form of Bisphosphonates
Does the patient have any special problems not listed above? ______________________________________________________ ________________________________________________________________________________________________________
EMERGENCY INFORMATION
Name of emergency contact person_____________________________________________________________________Relation____________________________________________ Phone #_____________________
ASAMBLEA REGIONAL DE MURCIA DIARIO DE SESIONES Año 2009 VII Legislatura Número 47 SESIÓN CELEBRADA EL DÍA 29 DE ABRIL DE 2009 ORDEN DEL DÍA (2.ª REUNIÓN) Diario de Sesiones - Pleno SUMARIO Para contestar a los portavoces de los grupos parlamentarios, En el turno para los grupos parlamentarios, interviene: Se levanta la sesión a las 18 h
APPLICATION NOTES January 2003 Automated Analysis of Kidney Stones requires a relatively large sample. Infrared improved this process, but it was still fairly the advent of computer technology and the introduction of Fourier transform infrared constituents (like cystine, cholesterol, bile salts, hemoglobin and protein); and process required grinding a small (1-6 mg) amount