New Patient Form Name_______________________________________ Date of Birth________________ Address________________________________________________________________ Appt Number_______ City ______________________ Postal Code ______________ Phone-HM (___) ____________ Cell (___) _____________ Bus (___) _____________ E-mail _________________________________________________________________ Physician _______________________________________ Phone (___) _____________ Emergency Contact _______________________________Phone (___) ____________ How did you hear about our office? ____________________________________________ Insurance information-Provider______________ Plan # _________ I.D. # _________ Secondary Insurance - Provider______________ Plan # _________ I.D. # _________ Secondary Insr Holder Name: ___________________________D.O.B. ____________ Health History
1.Have you been under the care of a Medical Doctor during the past two years?
If yes, please explain __________________________________________________________Physician name: _________________________Number:______________________________
2.Have you been hospitalized in the past two years?
If yes, please explain __________________________________________________________
3.When was your last complete physical examination? ______________________________________4.Have you recently, taken any prescription or over the counter medications?
If yes, please list: _____________________________________________________________ _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________5.Have you ever reacted adversely to any of the following? (If yes, please circle.)ANTIBIOTICS – Penicillin, Tetracycline, Sulfonamide, Metronidazole, Erythromycin, Clindamycin, other antibiotics _____________________________________________________________________ASPIRIN, IBUPROFEN, other anti-inflammatory medications ________________________________CODEINE, DEMEROL, PERCODAN, other pain relievers’ __________________________________BARBITURATES (sleeping pills) _______________________________________________________VALIUM, LOCAL ANAESTHETIC (dental freezing), NITROUS OXIDE. _____________________ Any other medications? _______________________________________________________________6.Have you ever been advised against taking any specific type of medication?
If yes, please explain __________________________________________________________
7.Do you have any of the following? Asthma, Hay Fever, Food Allergies, Metal or Latex Allergies, Skin Rashes, Hives, or any other allergic condition? (If yes, please circle.)Do any of these allergic conditions result in headache, nausea, swelling, shortness of breath, or chest constriction?
8.Does any immediate family member have diabetes?
9.Do you bleed excessively from a cut or injury, or bruise easily?
11.Has your weight, appetite, or energy level changed dramatically recently?
12.Do you experience shortness of breath or chest pain when climbing stairs?
14.Do you have Frequent severe headaches, earaches, ear/throat infections?
15.Have you ever had any injury or surgery to your face or jaws?
16.Are you alcohol and/or drug dependant?
17.Do you smoke or use any other forms of tobacco?
If so, in what amount: ________ cigarettes/day, for ________ years. Nicotine patch?________
Please Indicate which of the following you presently have or have ever had:
Please indicate by circling
18.Do you currently have, or have you had in the past, any disease, condition or problem not listed above? ____________________________________________________________________________19.Is there anything else about your health we should be aware of? ___________________________________________________________________________________________________________________________________________________________________________________________________
Child PatientHas the child recently had any of the following (please indicate year):Measles _______, Mumps _______, Chicken pox _______, Strep throat _______, Tonsillitis _______. Female Patients Are you pregnant or suspect you may be? Dental History
Date of your last Dental visit: _______________________ Last Cleaning _______________________
Last full mouth x-rays _______________________ Last Panorex x-ray _________________________
1. What do you feel is the most important feature about a Dental Office? ________________________
2. Are you having any pain or are you aware of any dental problem? ___________________________ _________________________________________________________________________________3. Have you ever had any of the following? (Please indicate year)
- Periodontal treatment? (treatment of the gums) __________________________________________
- Orthodontic treatment? (to straighten or realign teeth) ____________________________________ - Oral surgery? (surgery in or about the mouth or jaw) _____________________________________ - A bite plate adjusted or teeth ground? _________________________________________________ - Dental implants, or implant surgery in one or both of your jaw joints? ________________________
If yes to the last question, who performed the surgery? _______________________________
When was the surgery performed?________________________________________________
4. Are there any growths or sore spots in your mouth?
5. Do your gums bleed when brushing or eating?
6. Do you suffer from pain or swelling of your gums?
7. Have you noticed any loose teeth, or have any shifted?
9. Are any of your teeth sensitive to heat, cold, sweets, or pressure?
10. Do you use dental floss, proxabrush or stimudents? How often? ____________________________11. How often do you brush your teeth? __________________________________________________12. Have you experienced any of the following jaw problems: - Popping/clicking in your jaw joints?
- Pain in your jaw joints, around your ear, or side of your face?
- Difficulty in opening or closing your mouth?
13. Do you have any of the following habits? - Clenching or grinding your teeth while awake or asleep?
- Mouth breathing while asleep or awake?
- Placing foreign object in your mouth (pencils, nails, fingernails etc)
14. Do you have any emotional concerns about having dental treatment?
15. Are you happy with the appearance of your teeth?
If not, what would you like to change? ____________________________________________
16. Do you have any questions or concerns? _______________________________________________ ________________________________________________________________________________ ________________________________________________________________________________
I, the undersigned, certify that I have provided an accurate and complete personal and medical dental history and have not knowingly omitted any information. I have had the opportunity to ask questions and receive answers to the questions regarding my medical – dental history. I authorize the dentist to perform diagnostic procedures as may be required to determine necessary treatment. I understand that the information provided from or to my medical doctor or another health care provider may be necessary, and I consent to the release of this information. I understand that responsibility for payment of the dental services for myself and my dependents is mine, and I assume responsibility for fees associated with these services.
NOTE: IT IS IMPORTANT THAT ANY CHANGE IN YOUR HEALTH STATUS BE REPORTED TO OUR OFFICE.
Reviewed by treating Dentist __________________________
The format of this leaflet was determined by the Ministry of Health and its content was checked and approved by it in July 2010. NAME OF THE MEDICINAL PRODUCT QUANTITATIVE COMPOSITION IN TERMS OF THE ACTIVE INGREDIENT(S) PER DOSAGE FORM: 5 mg tablet: each tablet contains 5 mg of vardenafil (5.926 mg of vardenafil monohydrochloride trihydrate) 10 mg tablet: each tablet contains 10
DIRECTIONS FOR PARTNERS OF PERSONS WITH GONORRHEA OR GONORRHEA AND CHLAMYDIA PLEASE READ THIS VERY CAREFULLY Your sex partner has recently been diagnosed with one or more sexually transmitted diseases (STDs). This means that you may have been exposed to gonorrhea and/or chlamydia. You can get gonorrhea and chlamydia from having any kind of sexual contact (oral, vaginal, or anal) with a