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Patient Information
Patient Name: ___________________________________________ Date Of Birth: ___________________ CIRCLE APPROPRIATE ANSWER (Leave blank if you do not understand the question)
If NO, explain:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Yes No Has there been a change in your health within the last year? If YES, explain:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Yes No Are you being treated by a physician now? If YES, explain:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Name of physician _______________________________________________________________________Date of last medical examination ____________________________________________________________ HAVE YOU HAD OR DO YOU HAVE ANY OF THE FOLLOWING? (Please Check)
Describe any surgeries you have had.
__________________________________________________________________________________________________________________________________________________________________________ Yes No Have you been diagnosed with sleep apnea?Yes No Do you have a CPAP machine? Yes No If you do have a CPAP machine, are you comfortable with it? ARE YOU ALLERGIC TO OR HAVE YOU HAD A REACTION TO ANY OF THE FOLLOWING? (Please Check)
Other Allergies__________________________________________________________________________________________________________________________________________________________________________ MEDICATIONS AND PRESCRIPTIONS
Please list supplements, prescription or recreational drugs you are taking__________________________________________________________________________________________________________________________________________________________________________ ARE YOU TAKING OR HAVE YOU TAKEN ANY OF THE FOLLOWING IN THE LAST 3 MONTHS? (Please Check)
Yes No Do you have or have you had any other diseases or medical problems NOT listed on this form? If YES, explain:__________________________________________________________________________________________________________________________________________________________________________ Yes No Have you ever been pre-medicated for dental treatment? If YES, explain:__________________________________________________________________________________________________________________________________________________________________________ If YES, explain:__________________________________________________________________________________________________________________________________________________________________________ WOMEN ONLY
Yes No Are you taking birth control pills? The practice of dentistry involves treating the whole person. If the dentist determines that there may be a potential medically- compromised situation, medical consultation may be needed prior to commencement of dental treatment. I authorize the dentist to contact my physician. I have read and understand this form. To the best of my knowledge, I have answered every question completely and accurately. I will inform my dentist of any change in my health and/or medication. I will not hold my dentist, or any other member of his/her staff, responsible for any errors or omissions that I may have made in the completion of this form.
Signature of Patient (Write Adult name here) _________________________________ Date _______________


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511 Ave. R Brooklyn, NY 11223-2093 718 998 8171 Fax: 718 375 3263 Rabbi Moshe Shamah, Director Rabbi Ronald Barry, Administrator Halakhot of Purim I. Overview subsequently toward the service performed in it, later Subsequent to the destruction of the First Temple in transposed to that of the Temple. Since Haman Jerusalem by the Babylonians (586 B.C.E.) the proposed to pay 10,000 she

14.11.98 10 Jahre Alzheimer Gesellschaft Hannover Möglichkeiten und Grenzen der medikamentösen Behandlung bei Demenzerkrankungen - unter besonderer Berücksichtigung der Entwicklung der letzten Seit 10 Jahren leite ich die Gerontopsych. Klinik des Landeskrankenhauses, diederzeit 850 Patienten im Jahr behandelt, von denen die Hälfte unterDemenzerkrankungen mit psychiatrischen Folgesympt

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