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Health history

Name _________________________________ Social Security # ______-______-______ Sex _____ D.O. B. ___________________ Spouse or parent (if applicable) _______________________________ Employer __________________________________________ Home address _____________________________________________ City _______________ State _____ Zip _________________ Phone: Home (_____) _______-_______________ Work (_____) ______-_____________ Cell (_____) ______-_____________ 1. Is there any condition in your mouth, head, or neck causing you discomfort or swelling? . . . . . . . . . . . . . . . . . . . . . . . . . . . yes 2. Are you under a physician’s (doctor’s) care now? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . yes Doctor _________________________________ Reason ________________________________________ 3. Are you taking any medications at this time? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . yes no List ____________________________________________________________________________________ 4. Have you ever had a bleeding problem that needed medical treatment? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . yes 5. Have you ever been diagnosed with a heart murmur, heart defect, or have a pacemaker? . . . . . . . . . . . . . . . . . . . . . . . . . . . . yes 6. Have you ever had surgery, x-ray treatment, or been hospitalized or any major illness or injury? . . . . . . . . . . . . . . . . . . . . . . yes 7. Do you use tobacco? If so, what kind? __________________________ How often? ______________________________ yes 8. Are you pregnant? If so, how many months? _____________________________________________________________ yes 9. Do you have any artificial joints (hip, knee, elbow) or artificial heart valves? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . yes 10. Are you currently taking or have you ever taken a bisphosphonate medication such as Fosamax, Zometa, Actonel, Boniva, Aredia, Bonefos, Ostac, Skilid, Didronel? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . yes 11. Have you ever had any of the following diseases? (please circle) 12. Do you have any allergies (medication, latex, etc.)? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . yes 13. Do you have any reason to believe you have been exposed to AIDS or HIV? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . yes 14. Do you have any sores in your mouth that do not heal? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . yes 15. Is there any other information about your health we should know prior to treatment? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . yes List ______________________________________________________________________________________________ 16. Do you have dental insurance? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . yes Primary Insurance Company __________________________________________________________________________ Subscriber name ____________________________ D.O. B. ___________________ ID# ____________________ Secondary Insurance Company ________________________________________________________________________ Subscriber name ____________________________ D.O. B. ___________________ ID# ____________________
These answers I have given are true to the best of my knowledge. I am indicating my consent for routine dental procedures such as x-rays,
cleaning, fillings, crowns, and local anesthesia by signing below.
Patient or Parental consent _______________________________________________ Date ______________________

Source: http://nathanlukesdds.com/pdf/health_history.pdf

Thursday, november 3, 2005

PATIENT REPORTED OUTCOMES OF HORMONAL TREATMENTS FOR ACNE There are no comparative clinical trials on the comparative efficacy of the three hormonal preparations currently indicated in Canada for treatment of acne; namely Tri-Cyclen® (Ortho-McNeil), Alesse® (Wyeth), and Diane-35® (Berlex). Comparative effectiveness in acne for these 3 hormonal agents was sought from the Canadian acne epid

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