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PATIENT REGISTRATION & HISTORY
Please complete all information applicable.
q male q Female marital status: q single q married q Divorced q Widowed
Have we treated any member of the family:
Please list immediate family members and their ages:
MEDICAL HISTORY
Please check
Yes or
No to any of the following which you have had or have at present.
q
Y q
N aiDs
q
Y q
N Diabetes
q
Y q
N Heart Problems
q
Y q
N Pneumonia
q
Y q
N allergies
q
Y q
N Dizziness
q
Y q
N Hepatitis
q
Y q
N Polio
q
Y q
N arthritis
q
Y q
N Drug addiction
q
Y q
N High Blood Pressure
q
Y q
N Rheumatic Fever
q
Y q
N Artificial Implant/Valves
q
Y q
N ear infections
q
Y q
N Hypoglycemia
q
Y q
N sinus Problems
q
Y q
N Artificial Joint
q
Y q
N epilepsy
q
Y q
N Kidney Disease
q
Y q
N stroke
q
Y q
N asthma
q
Y q
N eye Problems
q
Y q
N Liver Disease
q
Y q
N Ulcers
q
Y q
N Blood Disorders
q
Y q
N Fainting
q
Y q
N meningitis
q
Y q
N Valley Fever
q
Y q
N Cancer
q
Y q
N Frequent Colds
q
Y q
N migraine
q
Y q
N Venereal Disease
q
Y q
N Chemotherapy
q
Y q
N Hay Fever
q
Y q
N mononucleosis
q
Y q
N Convulsions
q
Y q
N Headaches
q
Y q
N Pacemaker
are you taking, or have you ever taken any of the following Biophosphate drugs? if yes, please list the length of time you have been taking each one.
q Zometa q aredia q Fosamax q Boniva q actonel q skelid q Bonefos q Ostec q Didronel Others:
For the following questions, check Yes or No, whichever applies. Your answers are for our records only and will be considered confidential.
1. are you in good health?.q Yes q no
2. Has there been any change in your health within the last year? . q Yes q no
4. are you under the care of a physician at this time?. q Yes q no
5. Have you had any serious illnesses or operations? . q Yes q no
6. Have you been hospitalized within the last 5 years? . q Yes q no
7. are you taking any medication at this time? . q Yes q no
8. (Woman) are you pregnant or nursing at this time? . q Yes q no
9. Have you ever been physically abused/mistreated as a child or adult? . q Yes q no
10. Please list
any allergies or sensitivities (food, medication, pollens)
11. Do any of the following pertain to you as a child or as an adult? Please check:
q ever fallen from bike, skates, skis, walls, trees, anything
q Auto accident, motorcycle/ATV accident
DENTAL HISTORY
2. Have you had any problems associated with any previous dental treatment?
3. Have you or any member of your family had orthodontic treatment?4. Please check any of the following that you have ever had or now have.
q Pain in the joint: q Left q Right q side of face; q head; q neck
q Holds items in mouth (pencils/pins/nails/etc.)
explain:6. What is the main reason for your visit today, and what would you like to change about your smile?
Please advise us of any changes in your medical or dental history so that we can better care for you.
Source: http://www.drjaw.net/wp-content/uploads/2013/08/WEAVER-REGISTRATION-ADULT.pdf
CONVENIO INTERADMINISTRATIVO No. 10 – 2010 CONVENIO INTERADMINISTRATIVO DE UNION DE ESFUERZOS, COOPERACION, APORTES, TRANFERENCIA Y COMPETENCIAS PUBLICAS SUSCRITO ENTRE EL MUNICIPIO DE BUENAVISTA Y LA EMPRESAS PÚBLICAS DE VALOR: ( $ 357.652.600 ) OBJETO: LA SUSCRIPCION DE UN CONVENIO INTERADMINISTRATIVO DE UNION DE ESFUERZOS, COOPERACION, APORTES, TRANFERENCIA Y COMPETENCIAS PUBLICAS PARA
CONVOCATORIA Y DATOS GENER ALES DEL PROCE SO DE CONTRATACI ÓN S ERVICIO MUNIC IP AL DE AGUA P OTABLE Y AL CANT ARILLADO SANIT ARIO DE C OCHABAMBA - SEMAPA 1. CONV OCATOR IA Se convoca a la p resen tación de p ropuestas para el sig uiente proceso : S ERV ICIO MUNIC IPA L DE AGU A PO TAB LE Y AL CAN TAR ILLA DO S ANIT ARI O DE En tidad Convocan te : CO CHA BAMB A Mo d