MEDICAL AND DENTAL HISTORY (to be completed by patient)
Patient’s Full Name:_____________________________________ Date of Birth:___________________
Patient’s r Current r Previous Dentist(s):__________________________________________ Date of Last Dental Cleaning:______________
Patient’s r Current r Previous Physician(s):_______________________________________ Date of Last Physical Exam: _______________
A Please list your chief concerns for treatment: (# in order of priority):______________________________________________________________________ _________________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________________ B What or who motivated you to seek treatment and what do you expect?___________________________________________________________________ C List all current medications including non-prescriptions:_______________________________________________________________________________ _________________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________________ D List all drug allergies:____________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________________ E List previous surgeries:___________________________________________________________________________________________________________ __________________________________________________________________________________________________________________________________________________
Please describe all “Yes” answer (use space at bottom of page if necessary)
1 High Blood Pressure _______________________________ r 29 Pain, popping, catching or locking in jaw joints ________ r 2 Chest pains or heart attack __________________________ r 30 Clench or grind your teeth _________________________ r 3 Stroke ___________________________________________ r 4 Rheumatic Fever/Mitral Valve Prolapse ________________ r 31 Wake up with sore jaws ____________________________ r 5 Any heart trouble, murmur or mitral valve prolapse, Angina ____ r 32 Frequent headaches (How many per week?____) ______ r 6 Prosthetic devices (heart, valve, hip, knee, etc.) ________ r 33 Dizziness, ringing or pain in ears ____________________ r 7 Any lung disease (T.B., emphysema, etc.) ______________ r 8 Asthma ___________________________________________ r 34 Tenderness or stiffness in the jaw, neck or back _______ r 9 Allergies or hay fever ______________________________ r 35 History of TMJ (jaw joint) problems or therapy _________ r 10 Sinus problems __________________________________ r 36 Have you ever received instructions regarding care of your teeth or gums __ r 11 Mouth breathing or excessive snoring _______________ r 37 Treated for or told you have gum disease _____________ r 12 Ulcers or stomach problems _______________________ r 13 Diabetes _________________________________________ r 38 Treated or consulted for orthodontic therapy __________ r 14 Hepatitis or liver disease (Jaundice) __________________ r 39 Had head, neck or jaw injuries ______________________ r 15 Kidney or bladder disease _________________________ r 40 Dental x-rays taken in the last year __________________ r 16 Thyroid trouble ___________________________________ r 41 Brush your teeth (how often) _______________________ r 17 Connective tissue disease _________________________ r 18 Arthritis or rheumatism ____________________________ r 42 Floss your teeth (how often) ________________________ r 19 Cancer (type, date) ________________________________ r 43 Bad breath or unpleasant tastes in your mouth ________ r 20 Serious illness not listed (list type, date) _____________ r 44 Bleeding gums ___________________________________ r 21 Subject to prolonged bleeding or bruise easily ________ r 22 Glaucoma _______________________________________ r 45 Sore or painful teeth _______________________________ r 23 Epilepsy, convulsions or seizures ___________________ r 46 Tooth sensitivity (hot, cold, sweets) _________________ r 24 Do you have HIV (AIDS)? __________________________ r 47 Fever blisters or mouth ulcers ______________________ r 25 Are you taking any Bisphosphonates (Fosamax, Aredia, Didronel) _ r 48 Tongue thrusting habit ____________________________ r 26 Pregnant or possibly pregnant (Nursing) ______________ r 27 Using birth control medications _____________________ r 49 Place a high priority on keeping your natural teeth _____ r 28 Use tobacco (types/how much) _____________________ r 50 Do you like your smile __________________________________ r Please expand on the above information (refer to letter or number) or add anything you feel is important: ________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ The above information is accurate and complete to the best of my knowledge: Date: mm/dd/yy
__________ Patient or Guardian’s Signature: __________________________ Doctor’s Signature: ______________________
s Initials: _________ ,_________; _________, _________; _________, _________; _________, _________;_________;
1. Svendsen, Pernille Fog et al.: Polycystisk ovariesyndrom. Ugeskr læger 2005;167(34):3147 2. Madsbad S et al.: Fedme, metabolisk syndrom og hjerte-kar-sygdom. Ugeskr Læger 3. Jørgensen N et al.: Coordinated European investigations of semen quality: results from studies of Scandinavian young men is a matter of concern. Int J Androl 2006; 29(1):54-61 4. Kort HI et al.: Impact of body mass i
Inhibitory Effect of Carbon Dioxide on the Fed-Batch Culture of Ralstonia eutropha : Evaluation by CO Pulse Injection and Autogenous CO Methods Longan Shang,1* Min Jiang,1** Chul Hee Ryu,1 Ho Nam Chang,1 Soon Haeng Cho,2 Jong Won Lee3 1Department of Chemical and Biomolecular Engineering, Korea AdvancedInstitute of Science and Technology, 373-1 Guseong-dong, Yuseong-gu,Daejeon 305-701,