Answer all questions by circling Yes (Y) or No (N) All responses are kept confidential
Are you taking or have you ever taken Bisphospho-
nates for osteoporosis, multiple myeloma or other
cancers (Reclast, Fosamax, Actonel, Boniva,
4. Are you now under a physician’s care for
Have you ever been advised not to take a medication?
5. Have you ever had any serious illnesses,
K. Please list any and all medications taken, including
operations or hospitalizations? If so, describe:. Y N
prescription medications, diet drugs, over-the-counter
medications, herbal or holistic remedies, vitamins or
6. DO YOU HAVE OR HAVE YOU EVER HAD:
A. Rheumatic Fever or Rheumatic Heart Disease? . Y N
8. ARE YOU ALLERGIC TO OR HAVE YOU HAD AN
C. Cardiovascular Disease (Heart Attack, Heart
ADVERSE REACTION TO:
Trouble, Heart Murmur, Coronary Artery Disease,
A. Local Anesthesia (Novacain, etc.)? . Y N
Angina, High Blood Pressure, Stroke, Palpitations,
B. Penicillin or other antibiotics? . Y N
D. Lung Disease (Asthma, Emphysema, COPD, Chronic
Cough, Bronchitis, Pneumonia, Tuberculosis,
E. Seizures, Convulsions, Epilepsy, Fainting or
H. Chemicals or jewelry (rash or sensitivity)? . Y N
F. Bleeding Disorder, Anemia, Bleeding Tendency,
Other allergies or reactions? Please list. Y N
Blood Transfusion? Do you bruise easily? . Y N
G. Liver Disease (Jaundice, Hepatitis)? . Y N
10. Is there any past history of Alcohol or Chemical
Dependency or Emotional Disorder that may affect
11. Have you had any serious problems associated with
O. Implants placed anywhere in your body
12. Have you or an immediate family member had any
(Heart Valve, Pacemaker, Hip, Knee)? . Y N
problem associated with intravenous anesthesia? . Y N
P. Radiation (X-ray) treatment for Cancer? . Y N
13. Do you have any other disease, condition or
Q. Clicking or popping of jaw joint, pain near ear,
problem not listed above that you think the doctor
difficulty opening mouth, grind or clench teeth? . Y N
14. Do you wish to talk to the doctor privately
S. Any disease, drug or transplant operation
that has depressed your immune system? . Y N
15. Have you ever had a bone density scan? . Y N
7. ARE YOU USING ANY OF THE FOLLOWING:
16. FOR WOMEN ONLY
A. Are you Pregnant, or is there any chance
B. Anticoagulants (Blood Thinners)? . Y N
C. Aspirin or drugs such as Motrin, Aleve, Ibuprofen? . Y N
D. High Blood Pressure medications? . Y N
C. If you are using Oral Contraceptives, it is important
E. Steroids (Cortisone, Prednisone, etc.)? . Y N
that you understand that antibiotics (and some other
medications) may interfere with the effectiveness of oral
G. Insulin or Oral Anti-Diabetic drugs? . Y N
contraceptives. Therefore, you will need to use
H. Digitalis, Inderal, Nitroglycerin or other heart drug? Y N
mechanical forms of birth control for one complete cycle
of birth control pills, after the course of antibiotics or other medication is completed. Please consult with your physician for further guidance.
I understand the importance of a truthful and complete Health History to assist my dentist in providing the best care possible. I have had the opportunity to discuss my Health History with my dentist.
Signature of Person Completing Health History
Chief Dental Complaint: ________________________________________________________________________________________
____________________________________________________________________________________________________________
I have read and understand the above. Any questions I had about this form have been answered and I understand the answers. I understand it is my responsibility to fill out the form correctly and completely. Date: _____________ Patient’s Signature: _______________________________________ FOR COMPLETION BY THE DOCTOR
Comments on patient interview concerning medical history: _____________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
Significant findings from questions or oral interview: ___________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
Dental Management Considerations: _______________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
Dentist’s Signature: _______________________________________
Issue 16 – Urban areas Background There are fifteen townships in the Hurunui District, which provide services for the rural economy, and social and cultural facilities for the people of the District. The reasons for and purpose of providing a distinct management system for these urban areas generally come within two categories: the need to sustainably manage the different environmental
BIOTECH An Annual Journal of Dept. of Biotechnology Vol: 3, No. 1, Year : 2010 – 11; Page: 91-96 When Nature Fails, Test Tube Baby Prevails Jyotika Sharma, Kh. Beauty Singha, Raima Das and Shaheen Laskar Introduction One of the greatest boons for infertile couples is the development of Test Tube Baby . This incredible work was performed by Dr. Patrick Steptoe and Dr. Robert Ed