Thomas B. Braun, D.D.S., M.S., P.C. (Periodontal & Implant Dentistry) Medical History Form 2312 Plainfield Rd Crest Hill, IL 60403 (815) 744-7175) Referred By_________________________________ Date _______________ E-Mail Address_______________________ Name _______________________________________________ Home Phone ( )_____________________________ Last First Middle Address_____________________________________________ Business Phone ( )____________________________ Cell Phone ( ) _________________________ City ____________________________________ State __________ Zip Code___________________ Employer_______________________________ Job Title_________________________SS#________-_______-________ Date of Birth ______/______/______ Sex M F Height_______________ Weight________________ Mo Day Yr Name of Spouse ____________________Closest Relative______________________Phone ( ) _____________________
If you are completing this form for another person, your relationship to that person is?___________________________
Your answers to the following questions are for our records only and are considered confidential. You may be questioned during your visit on your response to the questions you answered. 1. Are you in Good health? Yes No 2. Have there been changes in your general health in the past year? Yes No 3. Physician(s) name and address __________________________________________ __________________________________________ __________________________________________ 4. Last Physical Exam _______/______/______ Did you have blood drawn at this physical? Yes No Mo. Day Yr. 5. Are you now under the care of your physician? Yes No If so what is the condition being treated? __________________________________________ 6. Have you had any serious illness, operation, or been hospitalized in the past 5 years? _______________________________________________________________________________________________ 7. List any medications – prescription or non-prescription that you are currently taking: _________________________________________________________________________________________________ ________________________________________________ ________________________________________________ 8. Are you on Aspirin Therapy? Yes No 9. Are you on Vitamin E Therapy? Yes No 10. Have you taken or are you taking Bizphosphanates (Fosamax, Actonel, Boniva, Didronel)? If yes please list which one(s) ____________________________________________________________________________________________ How long have you been taking? ____________ Do you have or had any of the following diseases or problems: 1. Damages or artificial heart valves? Yes No 2. Heart murmur or rheumatic heart disease? Yes No 3. Cardiovascular disease (heart trouble, heart attack, angina, coronary, insufficiency, coronary occlusion, high blood pressure, stroke or arteriosclerosis?) Yes No 4. Chest pain upon exertion? Yes No 5. Shortness of breath after mild exercise or when lying down? Yes No 6. Do you have inborn heart defects? Yes No 7. Cardiac pacemaker? Yes No 8. Seasonal Allergies? Yes No 9. Sinus trouble? Yes No 10. Asthma or hay fever? Yes No 11. Fainting or seizures? Yes No (Over) 12. Persistent diarrhea or weight loss? Yes No 13. Diabetes? Yes No Controlled? Yes No Blood Sugar Level: __________ Date: _________________ 14. Hepatitis, Jaundice, or liver disease? Yes No 15. Aids or HIV infection? Yes No 16. Thyroid problems? Yes No 17. Respiratory problems, emphysema, bronchitis etc? Yes No 18. Arthritis or painful swollen joints? Yes No 19. Stomach ulcer or hyperacidity? Yes No 20. Kidney trouble? Yes No 21. Tuberculosis? Yes No 22. Persistent cough, cough that produces blood or persistent swollen glands in neck? Yes No 23. Low blood pressure? Yes No 24. Sexually transmitted disease? Yes No 25. Epilepsy? Yes No 26. Problems with mental health? Yes No 27. Cancer? Yes No What Type? _______________________ Treatment Received? _________________________ 28. Problems of the immune system? Yes No 29. Abnormal bleeding? Yes No 30. Blood transfusion? Yes No 31. Blood disorder such as anemia? Yes No 32. Any treatment for tumor or growth? Yes No Are you allergic or have you had a reaction to: 1. Latex Allergy? Yes No 2. Local anesthetic? Yes No 3. Penicillin or other antibiotics? Yes No 4. Sulfa drugs? Yes No 5. Barbiturates, sedatives, or sleeping pills? Yes No 6. Aspirin? Yes No 7. Iodine? Yes No 8. Codeine or other narcotics? Yes No 9. Other? ___________________________________________________________________________________________ General Information 1. Do you have any disease, conditions, or problems not listed above you think I should know about? Yes No Explain: ___________________________________________________________________________________________ 2. Are you wearing contact lenses? Yes No 3. Are you wearing removable dental appliances? Yes No Women 1. Are you pregnant? Yes No 2. Are you nursing? Yes No 3. Are you taking birth control pills? Yes No I certify that I have read and understand the above. I acknowledge that my questions, if any, about the inquires set forth above have been answered to my satisfaction. 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 For completion by dentist: Comments on patient interview concerning medical history __________________________________ _____________________________________________________________________________________ Date: __________________________ Signature of Dentist:______________________________
INTERNATIONAL JOURNAL OF SCIENTIFIC & TECHNOLOGY RESEARCH VOLUME 2, ISSUE 10, OCTOBER 2013 The Effect Of Combination Of Octadecanoic Acid, Methyl Ester And Ribavirin Against Measles Virus Reagan Entigu Ak Linton @ Jerah, Samuel Lihan, Ismail bin Ahmad Abstract : Ribavirin is a broad spectrum antiviral drug and has been used to treat various diseases. It has been used as a treatment for sub
THE INFERTILITY SUPPORT NETWORK NEWSLETTER http://www.infertility-support.org.za August / September 2009 2009 – Issue 4 On a daily basis, each of us is bombarded by all types of influences – ranging from the people we meet and socialize with to the negative and positive experiences we did not plan for. Through it all, we need to extract the best from each experience so th