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Medical history questionare – update

MEDICAL HISTORY QUESTIONARE – UPDATE
Name _________________________________________ Address: _______________________________________ City, State, Zip: _____________________________________ Home Phone ________________ Cell Phone _________________ Work Phone _________________ What is your estimate of your current health? Poor ____________ Fair ____________ Good ____________
HAVE YOU EVER HAD THE FOLLOWING: YES
Hospitalization for illness or injury …. Arthritis………………………… • Aspirin, Ibuprofen…………….  • Penicillin…………………….….  • Sulfa………………………….…  • Codeine……………………….…  • Sedative…………………………  • Local Anesthetics……………….  • Latex……………………………  • Metals………………………….  • Any other allergies…………….  Heart problems…………………….…… Heart murmur……………………….…. Rheumatic fever………………………. Pacemaker…………………….………….  Stroke…………………….………………  Taken steroids within the last 2 years.  Artificial joint or heart valve……………. Ever taken Bisphosphonates (IV or Oral  (Actonel, Bonica, Fosamax, Skelid, Didronel, Aredia, Zometa, Bonefos) Anemia or other blood disorders………. Prolonged bleeding due to slight cut…….  Taking steroids…………………… Tuberculosis………………………….…. Presently being treated for illness…  Asthma/Emphysema………………….….  Aware of a change in your health…  Sinus problems…………………………. Often exhausted or fatigues…………  Kidney disease…………………………. Subject to frequent headaches………  Jaundice or Liver disease…………….….  A smoker – How many per day…….  Thyroid or parathyroid disease…………. Are you anxious about dentistry…….  Hormone deficiency………………….…. Easily upset…………………….….  High cholesterol………………………….  FEMALE – use birth control pills.…  Diabetes……………………………….… FEMALE – pregnant…………….…  Glaucoma………………………………. MALE – have prostate disorder……  Please describe any current medical treatment, impending or recent surgery, or other treatment that may possibly affect your dental treatment. ____________________________________________________________________________________ __________________________________________________________________________________________________ List (or attach a separate list if extensive) any medications taken within the last two years. __________________________________________________________________________________________________ __________________________________________________________________________________________________ PLEASE ADVISE US IN THE FUTURE OF ANY CHANGE IN YOUR MEDICAL
HISTORY OR ANY MEDICATIONS YOU MAY BE TAKING.
SIGNATURE ___________________________________________________________ DATE _____________
SIGNATURE ___________________________________________________________ DATE _____________
SIGNATURE ___________________________________________________________ DATE _____________

Source: http://www.nwprosthodontics.com/Documents/Medical%20History%20Questionnaire.pdf

Congestive heart failure case study.pdf

History: This seventy-nine year old, 69” in height, 182lbs. Caucasian male complains of shortness of breath and fatigue. The patient’s medical history includes hypertension, congestive heart disease and hemorrhoids. The patient was recently hospitalized for a coronary artery bypass surgery. The patient’s medications include aspirin one a day, potassium chloride 100mg one a day, furosemide 40

gdb.unibe.ch

A Selective HIV-Protease Assay Based on a Chromogenic Amino Acidby Fabrizio Badalassia)b), Hong Khan Nguyenc), Paolo Crottib), and Jean-Louis Reymond*a)a) Departement für Chemie und Biochemie, Universität Bern, Freiestrasse 3, CH-3012 Bern (fax:‡41316318057; e-mail: jean-louis.reymond@ioc.unibe.ch)b) Dipartimento di Chimica Bioorganica e Biofarmacia, UniversitaÁ di Pisa, I-56126 Pisac) Pr

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