Millard Hills Dental Health Center Nebraska Dental Implants Prosthetics Paul J. Sheridan, D.D.S. 14202 Y Street Gerald R. Gemar, D.D.S. Omaha, NE. 68137 William G. Carney, D.D.S. (402) 895 – 2085 Stuart J. McNally, D.D.S.
Please answer fully the following questions. This information is important for your health and our records. PATIENT_____________________________________________________________________________________________________ LAST NAME FIRST NAME SOC.SEC# BIRTHDATE __________________________________________________________________________________________________________________________________________ ADDRESS HOME PHONE WORK PHONE __________________________________________________________________________________________________________________________________________ YOUR EMPLOYER EMPLOYER’S ADDRESS __________________________________________________________________________________________________________________________________________ WHOM MAY WE THANK FOR REFERRAL YOUR DRIVERS LICENSE# __________________________________________________________________________________________________________________________________________ YOUR DENTAL INSURANCE CO. GROUP NUMBER SPOUSE’S DENTAL INSUR. CO. __________________________________________________________________________________________________________________________________________ SPOUSE’S NAME SPOUSE’S SOC.SEC.# SPOUSE’S EMPLOYER WORK PHONE __________________________________________________________________________________________________________________________________________ SPOUSE’S EMPLOYER’S ADDRESS SPOUSE’S DATE OF BIRTH __________________________________________________________________________________________________________________________________________ FAMILY PHYSICIAN ADDRESS OFFICE __________________________________________________________________________________________________________________________________________ PERSON RESPONSIBLE FOR PAYMENT STATE PHONE # (If different from patient) __________________________________________________________________________________________________________________________________________ NEAREST LIVING RELATIVE OR PERSON TO CALL IN AN EMERGENCY OTHER THAN SPOUSE
Please write YES or NO in the space provided
Are you receiving medical treatment now?________________If yes, what?_______________________________________________ Are your subject to prolonged bleeding following injury, surgery or extractions?__________If yes, explain____________________ Have you had any adverse response to Novocaine, penicillin, or any other drug?__________If yes, explain____________________ Are you subject to headaches___________,fainting___________, or dizziness?____________________________________________ Are you taking any medication at this time?___________If yes, please list________________________________________________ Have you had any major surgery or major illness?_____________If yes, please list________________________________________ Have any wounds healed slowly or presented other complications?__________If yes, please describe_________________________ Have you ever been a patient in the hospital during the past 2 years?_________If yes, please explain_________________________ When you walk up stairs or take a walk do you ever have to stop because of pain in your chest, shortness of breath, or because you are very tired?_________If yes, please explain_________________________________________________________________ Do your ankles swell during the day?_______________Do you sleep with two or more pillows?______________________________ Do you ever wake up short of breath?______________If yes, please explain_______________________________________________ Have you lost or gained more than 10 pounds in the past year?___________If yes, please explain____________________________ Are you on a special diet?______________If yes, please explain_________________________________________________________ Has your medical doctor ever said you have cancer or tumor?__________If yes, please describe_____________________________ Circle any of the following you have or have had: Heart Failure X-ray or Cobalt treatment Breast Augmentation Heart Disease or Attack Kidney/Dialysis Chemotherapy (cancer, leukemia) Blood Transfusion Angina Pectoris Arthritis Drug Addiction/Alcoholism High Blood Pressure Blood Disorders Rheumatism Hemophilia Heart Murmur Emphysema Cortisone/Steroid Medication Mitral Valve Prolapse Rheumatic Fever Cough Glaucoma Cold Sores Congenital Heart Lesions/or defects Tuberculosis (TB) Pain in Jaw Joints Epilepsy or seizures Scarlet Fever Stomach, intestinal disorders Fainting or Dizzy Spells Artificial Heart Valve Hay Fever AIDS/H IV Genital Herpes Heart Pacemaker Sinus Trouble Hepatitis A (infectious) Nervousness Heart Surgery Allergies or Hives Hepatitis B (Serum) Psychiatric Treatment Artificial Joints Diabetes Liver Disease Sickle Cell Disease Thyroid Disease Yellow Jaundice Bruise Easily Venereal Disease(syphilis,gonorrhea) Headaches Tobacco use Mentally Handicapped
Do you have any disease, condition or problem not listed?__________If yes, please describe________________________________ Have you had a reaction to any metal including jewelry?__________Latex or Rubber?____________________________________ WOMEN: Are you pregnant now?___________Do you anticipate becoming pregnant?____________________________________ PATIENT DENTAL HISTORY Have you ever had any inflamed areas, growth, or sore spots in or around your mouth?____________________________________ Do you experience popping or discomfort in your jaw?_______Do you habitually clench or grind your teeth during the night or day?_________Limited opening?________Locking episodes?____________Buzzing or ringing in ears?___________________ Have you recently had: Bleeding gums?__________________________________ Food catching between teeth?___________________________________ Spaces developing between teeth?_____________________ Change in color of teeth or gums?______________________________ Bad Breath?______________________________________ Teeth sensitive to hot, cold, or sweets?___________________________ Crowding teeth developing?_________________________ Teeth tender to chew on?______________________________________ Do you, presently have any dental complaints?_________________________If so, please list_________________________________ Have you ever had any unfavorable dental experiences?_______________________________________________________________ Have you ever had instruction on the correct method of brushing and flossing your teeth?__________________________________ How often do you brush?________________________________Floss?___________________________________________________ What are some questions about dentistry and oral health that we may answer for you?_____________________________________ ______________________________________________________________________________________________________________ How can we make the appointment easier for you?___________________________________________________________________ Date of last dental visit__________What was done?_________________________________________Dental X-rays taken?_______
1. (a) Think the appearance of my mouth is excellent.
2. (a) Will do anything to keep my natural teeth.
(b) Satisfied with the appearance of my mouth.
(b) Want to keep my teeth, but have a certain budget.
(c) Dissatisfied with the appearance of my mouth.
(c) Don’t care whether or not I keep them.
3. (a) Have set goals for my oral health with a previous dentist.
4. (a) Put dentistry for myself & family high on my
(b) Want to set goals concerning my dental health.
(c ) Never set goals concerning my oral health. (b) Put dentistry for myself & family low on my
( c) Is on my list of priorities, but hard to find.
THANK YOU FOR YOUR ASSISTANCE “To the best of my knowledge, all of the preceding answers are correct. If I ever have any change in my health, or if my medicines change, I
will inform the dentist at the next appointment without fail”. I authorize my DDS to contact my physician for any additional information.
MILLARD HILLS DENTAL HEALTH CENTER NEBRASKA DENTAL IMPLANT PROSTHETICS Paul J. Sheridan, D.D.S. 14202 Y Street Gerald R. Gemar, D.D.S. Omaha, NE. 68137 William G. Carney, D.D.S. (402) 895-2085 Stuart J. McNally, D.D.S.
Please answer fully the following questions. This information is important for your health and our records. PATIENT_____________________________________________________________________________________________________ LAST NAME FIRST NAME SOC.SEC# BIRTHDATE __________________________________________________________________________________________________________________________________________ ADDRESS HOME PHONE WORK PHONE __________________________________________________________________________________________________________________________________________ YOUR EMPLOYER EMPLOYER’S ADDRESS __________________________________________________________________________________________________________________________________________ WHOM MAY WE THANK FOR REFERRAL YOUR DRIVERS LICENSE# __________________________________________________________________________________________________________________________________________ YOUR DENTAL INSURANCE CO. GROUP NUMBER SPOUSE’S DENTAL INSUR. CO. __________________________________________________________________________________________________________________________________________ SPOUSE’S NAME SPOUSE’S SOC.SEC.# SPOUSE’S EMPLOYER WORK PHONE __________________________________________________________________________________________________________________________________________ SPOUSE’S EMPLOYER’S ADDRESS SPOUSE’S DATE OF BIRTH __________________________________________________________________________________________________________________________________________ FAMILY PHYSICIAN ADDRESS OFFICE __________________________________________________________________________________________________________________________________________ PERSON RESPONSIBLE FOR PAYMENT STATE PHONE # (If different from patient) __________________________________________________________________________________________________________________________________________ NEAREST LIVING RELATIVE OR PERSON TO CALL IN AN EMERGENCY OTHER THAN SPOUSE
Please write YES or NO in the space provided
Are you receiving medical treatment now?________________If yes, what?_______________________________________________ Are your subject to prolonged bleeding following injury, surgery or extractions?__________If yes, explain____________________ Have you had any adverse response to Novocaine, penicillin, or any other drug?__________If yes, explain____________________ Are you subject to headaches___________,fainting___________, or dizziness?____________________________________________ Are you taking any medication at this time?___________If yes, please list________________________________________________ Have you had any major surgery or major illness?_____________If yes, please list________________________________________ Have any wounds healed slowly or presented other complications?__________If yes, please describe_________________________ Have you ever been a patient in the hospital during the past 2 years?_________If yes, please explain_________________________ When you walk up stairs or take a walk do you ever have to stop because of pain in your chest, shortness of breath, or because you are very tired?_________If yes, please explain_________________________________________________________________ Do your ankles swell during the day?_______________Do you sleep with two or more pillows?______________________________ Do you ever wake up short of breath?______________If yes, please explain_______________________________________________ Have you lost or gained more than 10 pounds in the past year?___________If yes, please explain____________________________ Are you on a special diet?______________If yes, please explain_________________________________________________________ Has your medical doctor ever said you have cancer or tumor?__________If yes, please describe_____________________________ Circle any of the following you have or have had: Heart Failure X-ray or Cobalt treatment Breast Augmentation Heart Disease or Attack Kidney/Dialysis Chemotherapy (cancer, leukemia) Blood Transfusion Angina Pectoris Arthritis Drug Addiction/Alcoholism High Blood Pressure Blood Disorders Rheumatism Hemophilia Heart Murmur Emphysema Cortisone/Steroid Medication Mitral Valve Prolapse Rheumatic Fever Cough Glaucoma Cold Sores Congenital Heart Lesions/or defects Tuberculosis (TB) Pain in Jaw Joints Epilepsy or seizures Scarlet Fever Stomach, intestinal disorders Fainting or Dizzy Spells Artificial Heart Valve Hay Fever AIDS/H IV Genital Herpes Heart Pacemaker Sinus Trouble Hepatitis A (infectious) Nervousness Heart Surgery Allergies or Hives Hepatitis B (Serum) Psychiatric Treatment Artificial Joints Diabetes Liver Disease Sickle Cell Disease Thyroid Disease Yellow Jaundice Bruise Easily Sexual Transmitted Disease (STD) Headaches Tobacco use Mentally Handicapped
Do you have any disease, condition or problem not listed?__________If yes, please describe________________________________ Have you had a reaction to any metal including jewelry?__________Latex or Rubber?____________________________________ WOMEN: Are you pregnant now?___________Do you anticipate becoming pregnant?____________________________________ PATIENT DENTAL HISTORY Have you ever had any inflamed areas, growth, or sore spots in or around your mouth?____________________________________ Do you experience popping or discomfort in your jaw?_______Do you habitually clench or grind your teeth during the night or day?_________Limited opening?________Locking episodes?____________Buzzing or ringing in ears?___________________ Have you recently had: Bleeding gums?__________________________________ Food catching between teeth?___________________________________ Spaces developing between teeth?_____________________ Change in color of teeth or gums?______________________________ Bad Breath?______________________________________ Teeth sensitive to hot, cold, or sweets?___________________________ Crowding teeth developing?_________________________ Teeth tender to chew on?______________________________________ Do you, presently have any dental complaints?_________________________If so, please list_________________________________ Have you ever had any unfavorable dental experiences?_______________________________________________________________ Have you ever had instruction on the correct method of brushing and flossing your teeth?__________________________________ How often do you brush?________________________________Floss?___________________________________________________ What are some questions about dentistry and oral health that we may answer for you?_____________________________________ ______________________________________________________________________________________________________________ How can we make the appointment easier for you?___________________________________________________________________ Date of last dental visit__________What was done?_________________________________________Dental X-rays taken?_______
1. (a) Think the appearance of my mouth is excellent.
2. (a) Will do anything to keep my natural teeth.
(b) Satisfied with the appearance of my mouth.
(b) Want to keep my teeth, but have a certain budget.
(c) Dissatisfied with the appearance of my mouth.
(c) Don’t care whether or not I keep them.
3. (a) Have set goals for my oral health with a previous dentist.
4. (a) Put dentistry for myself & family high on my
(b) Want to set goals concerning my dental health.
(c ) Never set goals concerning my oral health. (b) Put dentistry for myself & family low on my
( c) Is on my list of priorities, but hard to find.
THANK YOU FOR YOUR ASSISTANCE “To the best of my knowledge, all of the preceding answers are correct. If I ever have any change in my health, or if my medicines change, I
will inform the dentist at the next appointment without fail”. I authorize my DDS to contact my physician for any additional information.
Signature____________________________________________________________________Date______________________________
Boletim Mensal Número 60 19 / Nov / 2003 Ambiente Macroeconômico e de InvestimentosO humor econômico manteve-se bastante favorável nessas últimas semanas, amparado pela satisfatóriaevolução dos resultados fiscais e externos, pelas baixas taxas de inflação e pelos sinais de recuperaçãona atividade econômica. As variáveis financeiras comemoram esse ambiente com novas altas na
MEDICATION GUIDE DEXILANT (decks-i-launt) (dexlansoprazole) delayed-release capsules Read this Medication Guide before you start taking DEXILANT and each time you get a refill. There may be new information. This information does not take the place of talking to your doctor about your medical condition or your treatment. What is the most important information that I should know ab