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Medical history questionare – update

MEDICAL HISTORY QUESTIONARE – UPDATE
Name _________________________________________ Address: _______________________________________ City, State, Zip: _____________________________________ Home Phone ________________ Cell Phone _________________ Work Phone _________________ What is your estimate of your current health? Poor ____________ Fair ____________ Good ____________
HAVE YOU EVER HAD THE FOLLOWING: YES
Hospitalization for illness or injury …. Arthritis………………………… • Aspirin, Ibuprofen…………….  • Penicillin…………………….….  • Sulfa………………………….…  • Codeine……………………….…  • Sedative…………………………  • Local Anesthetics……………….  • Latex……………………………  • Metals………………………….  • Any other allergies…………….  Heart problems…………………….…… Heart murmur……………………….…. Rheumatic fever………………………. Pacemaker…………………….………….  Stroke…………………….………………  Taken steroids within the last 2 years.  Artificial joint or heart valve……………. Ever taken Bisphosphonates (IV or Oral  (Actonel, Bonica, Fosamax, Skelid, Didronel, Aredia, Zometa, Bonefos) Anemia or other blood disorders………. Prolonged bleeding due to slight cut…….  Taking steroids…………………… Tuberculosis………………………….…. Presently being treated for illness…  Asthma/Emphysema………………….….  Aware of a change in your health…  Sinus problems…………………………. Often exhausted or fatigues…………  Kidney disease…………………………. Subject to frequent headaches………  Jaundice or Liver disease…………….….  A smoker – How many per day…….  Thyroid or parathyroid disease…………. Are you anxious about dentistry…….  Hormone deficiency………………….…. Easily upset…………………….….  High cholesterol………………………….  FEMALE – use birth control pills.…  Diabetes……………………………….… FEMALE – pregnant…………….…  Glaucoma………………………………. MALE – have prostate disorder……  Please describe any current medical treatment, impending or recent surgery, or other treatment that may possibly affect your dental treatment. ____________________________________________________________________________________ __________________________________________________________________________________________________ List (or attach a separate list if extensive) any medications taken within the last two years. __________________________________________________________________________________________________ __________________________________________________________________________________________________ PLEASE ADVISE US IN THE FUTURE OF ANY CHANGE IN YOUR MEDICAL
HISTORY OR ANY MEDICATIONS YOU MAY BE TAKING.
SIGNATURE ___________________________________________________________ DATE _____________
SIGNATURE ___________________________________________________________ DATE _____________
SIGNATURE ___________________________________________________________ DATE _____________

Source: http://www.nwprosthodontics.com/Documents/Medical%20History%20Questionnaire.pdf

servalor.unistra.fr

use of synthetic antimicrobial peptides to facilitate the our laboratory identified molecules having the ability to boost the effectiveness of anti-infective agents. these molecules have themselves anti-infective properties (antibacterial and antifungal) and are able to increase the effectiveness of antibiotics already commercially available. We study the effect of different synthetic peptides

Kosmetik produkte

Schlankheitsmittelliste (Stand 11. 1. 2011) Hinweis: Suchen Sie bestimmte Produkte? Dann tippen Sie den Namen in das Suchfeld oben rechts in Ihrem pdf-Dokument und drücken Sie auf Enter. Eine weitere Möglichkeit ist, dass Sie die „Strg“-Taste + die „F“-Taste drücken. Auch so können Sie Ihr gesuchtes Wort eingeben und die Suche starten. Appetithemmer auf chemischer Basis

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