Patient name ____________________________________________ date___________________


PATIENT NAME ____________________________________________ DATE___________________
Primary reason for this dental appointment
Do you have a specific dental problem? __________________________________________________________________ Do you have dental examinations on a routine basis? Last visit_______________________________________________ Do you think you have active decay or gum disease?_______________________________________________________ Do you brush and floss on a routine basis?__________________________________________________________________ Do your gums ever bleed? Discuss__________________________________________________________________________ Do you like your smile? Why________________________________________________________________________________ Yes No Does food catch between your teeth?Any loose teeth?_____________________________________________________ Do you want to keep your remaining teeth?________________________________________________________________ Do you ever have clicking, popping or discomfort in the jaw joint?___________________________________________ Are you interested in doing away with removable dentures or partial dentures?______________________________ Do you smoke or chew? Any sores or growths in your mouth? Discuss________________________________________ Name of Previous Dentist(optional)_________________________________________________________________________ Date of last full mouth x-rays (16 small films or panoramic):___________________________________________________ Are you under a physician’s care now?Why_________________________________________________________________ Yes No Have you ever been hospitalized or had a major operation? Discuss _________________________________________ Yes No Have you ever had a serious injury to your head or neck? Discuss____________________________________________ Are you taking any medications, pills or drugs? What?_______________________________________________________ Yes No Are you allergic to any medications or substances? Please check below _____________________________________ Are you taking or have you ever taken bisphosphanate medication(such as Actonel, Aredia, Boniva, Fosamax, Zom Bonefos, Ostac, Skelid, Didronel) ___________________________________________________________________________ Do you have any problems with *snoring *daytime sleepiness *apnea? ________________________________________ Yes No Do you now have or have you ever had any of the following? Please check appropriate boxes. *If yes to any of the starred conditions, please call prior to your appointment… premedication may be required Have you ever had any other serious il ness not checked above? Discuss ________________________________________Yes No Do you wish to talk to the dentist privately about any problem? __________________________________________________Yes No To the best of my knowledge, all of the preceding answers are correct. If I have any changes in my health status or if my medicines change, I shall inform the dentist and staff at the next appointment without fail. X ________________________________________________________________________________ Date _____________________________ Reviewed by Doctor______________________________________________________________ Date ______________________________ History Review and Significant Findings: ________________________________________________________________________________ ______________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________


05 posted pdl 365wellst_23

2005 Prescription Drug List Consumer Reference GuideYou have choices in the prescription medications you and your doctor select to treat you. Understanding them will help you make more informed health care decisions. Your pharmacy benefit provides you with many choices. This booklet will help you understandthose choices. It will also enable you to ask your doctor or pharmacist the right question

RECOMENDACIÓN POSTOPERATORIAS PARA BYPASS GASTRICO PAUTAS DE ALIMENTACIÓN. Es muy importante que siga el plan nutricional (dieta) que le ha entregado la nutricionista para evitar molestias gástricas, proteger la integridad del saco gástrico grapado y suturado. El programa nutricional está compuesto por cuatro etapas a fin de reiniciar gradualmente su estomago a las comidas de consi

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