Patient name ____________________________________________ date___________________

PATIENT NAME ____________________________________________ DATE___________________
Primary reason for this dental appointment
Do you have a specific dental problem? __________________________________________________________________ Do you have dental examinations on a routine basis? Last visit_______________________________________________ Do you think you have active decay or gum disease?_______________________________________________________ Do you brush and floss on a routine basis?__________________________________________________________________ Do your gums ever bleed? Discuss__________________________________________________________________________ Do you like your smile? Why________________________________________________________________________________ Yes No Does food catch between your teeth?Any loose teeth?_____________________________________________________ Do you want to keep your remaining teeth?________________________________________________________________ Do you ever have clicking, popping or discomfort in the jaw joint?___________________________________________ Have your past experiences in a dental office always been positive?________________________________________ Do you smoke or chew? Any sores or growths in your mouth? Discuss________________________________________ Name of Previous Dentist(optional)_________________________________________________________________________ Date of last full mouth x-rays (16 small films or panoramic):___________________________________________________ Are you under a physician’s care now?Why_________________________________________________________________ Yes No y Have you ever been hospitalized or had a major operation? Discuss _________________________________________ Yes No Have you ever had a serious injury to your head or neck? Discuss____________________________________________ Are you taking any medications, pills or drugs? What?_______________________________________________________ Yes No Are you on a special diet? Discuss__________________________________________________________________________ Are you allergic to any medications or substances? Please check below _____________________________________ Have you ever taken bisphosphanate medication(such as Actonel, Aredia, Boniva, Fosamax, Zometa, Bonefos, Ostac, Skelid, Didronel) ___________________________________________________________________________ Do you now have or have you ever had any of the following? Please check appropriate boxes. *If yes to any of the starred conditions, please call prior to your appointment… premedication may be required Have you ever had any other serious il ness not checked above? Discuss ________________________________________Yes No Do you wish to talk to the dentist privately about any problem? __________________________________________________Yes No To the best of my knowledge, all of the preceding answers are correct. If I have any changes in my health status or if my medicines change, I shall inform the dentist and staff at the next appointment without fail. X ________________________________________________________________________________ Date _____________________________ Reviewed by Doctor______________________________________________________________ Date ______________________________ History Review and Significant Findings: ________________________________________________________________________________ ______________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________ DENTAL AND MEDICAL HISTORIES


Tomoya Baba1), Satoshi Katagiri1), Hiroshi Tanoue1), Chiden1), Shoko Saji1), Masao Hamada1), Marina Nakashima1), Masako Okamoto1), Mika Institute of the Society for Techno-innovation of Agriculture, Forestry and FisheriesKamiyokoba, Tsukuba, Ibaraki, 305-0854, Japan1)National Institute of Agrobiological ResourcesKannnondai, Tsukuba, Ibaraki, 305-8602, Japan2)A P1-derived artificial chromosom

03-0052 cad

Clinical Performance Measures Chronic Stable Coronary Artery Disease Tools Developed by Physicians for Physicians American College of Cardiology American Heart Association Physician Consortium for Performance Improvement Purpose This measurement tool provides physicians with evidence-based 1 clinical performance measures, including a data collection flowsheet, that may be useful

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