MEDICAL HISTORY QUESTIONNAIRE NAME: Mr./Miss/Mrs./Ms./Dr.
DATE OF BIRTH: (DAY/MONTH/YEAR):
HOME ADDRESS: __________________________________________________ IN CASE OF EMERGENCY, WE SHOULD NOTIFY: CITY: __________________________________________ NAME: ________________________________________________ POSTAL CODE: __________________________________ _________________________________ HOME: _____________________________________________________ DAY-TIME PHONE: _________________________________ CELL: ___________________________________ _______ FAMILY PHYSICIAN: _____________________________ WORK: ___________________________________ _______ PHONE: ________________________________________ EMAIL: __________________________________________ WHO REFERRED YOU: EMPLOYER: ______________________________ _______ ________________________________________________ THE FOLLOWING INFORMATION IS REQUIRED TO ENABLE US TO PROVIDE YOU WITH THE BEST POSSIBLE DENTAL CARE. ALL INFORMATION IS STRICTLY PRIVATE AND IS PROTECTED BY DOCTOR-PATIENT CONFIDENTIALITY. THE DENTIST WILL REVIEW THE QUESTIONS AND EXPLAIN ANY THAT YOU DO NOT UNDERSTAND. PLEASE FILL IN THE ENTIRE FORM. 1. Are you being treated for any medical condition at the present or have you been treated within the past year? If so, why? Not Sure/Maybe
2. When was your last dental check up? ____________________________________________________________________________________________________________________ 3. Has there been any change in your general health in the past year? If yes, please explain. Not Sure/Maybe ____________________________________________________________________________________________________________________ 4. Do you currently have any of the following? Please Circle Coughing High fever Open Sores Vomiting Diarrhea 5. Are you taking or have you taken any medications, non-prescription drugs or herbal supplements in the past 6 months? (e.g. Vitamins, Dietary supplements, Herbal supplements) N o t S u r e / Maybe If yes, please list…
5b: Have you used cocaine, marijuana or any other drugs in the past year? Please List… Yes No Not Sure/Maybe _____________________________________________________________________________________________________________________ 6. Do you have any allergies? If yes, please list using the categories below:
Not Sure/Maybe a) medications b) latex/rubber products c) other e.g. hayfever, foods _______________________________________________________________________________________________________________ 6b: Have you been diagnosed with any new allergies in the past year? Not Sure/Maybe _______________________________________________________________________________________________________________ 7. Have you ever had a peculiar or adverse reaction to any medicines or injections? Not Sure/Maybe If yes, please explain.
8. Do you have or have you ever had Asthma? Not Sure/Maybe _____________________________________________________________________________________________________________ 9. Do you have or have you ever had any Heart or Blood Pressure problems? Not Sure/Maybe ______________________________________________________________________________________________________________ 10. Do you have or have you ever had an artificial heart valve, a history of infective endocarditis, a heart transplant or a congenital heart defect? Please List:
10b: Do you have a pace maker? Yes No Not Sure/Maybe 11. Do you have a prosthetic or artificial joint? Not Sure/Maybe
12. Have you ever been advised by your doctor to take antibiotics before dental treatment?
13. Do you have any conditions or therapies that could affect your immune system: Please Circle Leukemia AIDS HIV infection Radiotherapy Chemotherapy 14. Have you ever had hepatitis A, B, or C, jaundice or liver disease?
15. Do you have a bleeding problem or bleeding disorder? Not Sure/Maybe
16. Have you ever been hospitalized for any illnesses or operations? If yes, please explain.
17. Do you have or have you ever had any of the following? Please circle. chest pain, angina shortness of breath steroid therapy seizures(epilepsy) kidney disease heart attack prosthetic heart valve lung disease diabetes tuberculosis stomach ulcers thyroid disease arthritis diet pill therapydrug/alcohol dependency 18. Are there any conditions not listed above that you have or have had? If so, what?
19. Are there any diseases or medical problems that run in your family? (e.g. diabetes, cancer or heart disease) Not Sure/Maybe
20. Are you taking or have you taken Bisphosphonate Therapy (bone density medication)? If so, how long? (E.g. Actonel, Boniva, Fosamax, Skelif, Didronel) Not Sure/Maybe
21. Do you smoke or chew tobacco products? Not Sure/Maybe
22. Are you nervous during dental treatment? Not Sure/Maybe
23. Have you ever had difficulty becoming anesthetized (numb) for dental procedures?
24.For Women Only: Are you pregnant or breast feeding? If pregnant, what is the expected delivery date?
To the best of my knowledge, the above information is correct: PATIENT/PARENT/GUARDIAN SIGNATURE: ____________________________ ______________ DATE: ____________________________ I UNDERSTAND and agree that I AM RESPONSIBLE for payment of all dental services provided to me and/or my dependents. I hereby assign my benefits, payable from claims submitted electronically or manually, to Nose Creek Dental Centre and authorize payment directly to the providing dentist. Please be advised that it is your responsibility to understand your Insurance Guidelines.
______________________________ Signature of Patient/Parent or Guardian INSURANCE INFORMATION(Primary Plan) Name of Insured: __________________________________ D.O.B. Day ________ Month ________ Year ________ Address: _______________________________________________ Postal Code: __________________ Home Phone: __________________ Work: _________________ Ext: ______ Cell: ______________________ Name of Employer: ___________________________________ Name of Ins. Company: _________________ Group/Policy No. ________________ Cert./ID No. ____________________ Cov. No. ___________________ INSURANCE INFORMATION(Secondary Plan if applicable) Name of Insured: ___________________________________ D.O.B. Day ________ Month ________ Year ________ Address: _________________________________________________ Postal Code: __________________ Home Phone: __________________ Work: _________________ Ext: ______ Cell: _______________________ Name of Employer: ___________________________________ Name of Ins. Company: _________________ Group/Policy No. ________________ Cert./ID No. _____________________ Cov. No. ______________________ INSURANCE INFORMATION(Third Plan if applicable) Name of Insured: ___________________________________ D.O.B. Day ________ Month ________ Year ________ Address: ____________________________________________________ Postal Code: __________________ Home Phone: __________________ Work: _________________ Ext: ______Cell: ________________________ Name of Employer: ___________________________________ Name of Ins. Company: __________________ Group/Policy No. _________________ Cert./ID No. _____________________ Cov. No. _________________ CONSENT FOR COLLECTION AND RELEASE OF INFORMATION
We are committed to protecting the privacy of our patient’s personal information and to utilizing all personal information in a
responsible and professional manner. This document summarizes some of the personal information that we collect, use and disclose.
In addition to the circumstances in this form, we also collect, use and disclose personal information when permitted or required by
We collect information from our patients such as names, home addresses, work addresses, home telephone numbers, work telephone
numbers, email addresses, credit card information, social insurance numbers and private dental insurance information. (Collectively
referred to as “Contact Information”). Contact information is collected and used for the following purposes:
To invoice patients for dental services, to process credit card payments, and to collect unpaid accounts.
To process claims for payment or reimbursement from third-party health benefit providers and insurance companies.
To send reminders to patients concerning the need for further dental examination or treatment.
To send patients informational material about our dental materials.
To follow up with treatment and/or customer service.
Contact information is disclosed to third party health benefit providers and insurance companies where the patient has submitted a
claim for reimbursement or payment of all or part of the cost of dental treatment or has asked us to submit a claim on the patients
Financial information may be collected in order to make arrangements for the payment of dental services or to provide a form of
We collect information from our patients about their health history, their family health history, physical condition, and dental
treatments. (Collectively referred to as “Medical Information”). Patient’s medical information is collected and used for the purpose
of diagnosing dental conditions and providing dental treatment.
Patients Medical Information is disclosed for the following purposes:
To third party health benefit providers and insurance companies where the patient has submitted a claim for reimbursement or payment of all or part of the cost of dental treatment or has asked us to submit a claim on the patient’s behalf.
To other dentists and dental specialists, where we are seeking a second opinion and the patient has consented to us obtaining a second opinion.
To other dentists and dental specialists, if the patient, with their consent, has been referred by us to the other dentist or dental specialist for treatment.
To other dentists and dental specialists where those dentists have asked us, with the consent of the patient, to provide a second opinion.
To other health care professionals such as physicians if the patient, with their consent, has been referred by us to the other health care professional for either a second opinion or treatment.
If we are ever considering selling all or part of our dental practice, qualified potential purchasers may be granted access as part of the
due diligence process to patient information in order to verify information important to the potential sale. If this occurs, we will take
steps to ensure that the prospective purchaser safeguards all personal information.
Dentists are regulated by the Alberta Dental Association and College, which may inspect our records and interview our staff as part of
its regulatory activities in the public interest.
I consent to the collection, use and disclosure of my personal information as set out above.
_________________________ ______________________________ _________________________
“ESTRATEGIAS PARA EL DIAGNOSTICO Y EL MANEJO RACIONAL DE LAS DISKALEMIAS” GRUPO DE TRABAJO FISIOLOGIA CLINICA RENAL INTRODUCCION El potasio es el principal catión del líquido intracelular (LIC, 150 mEq/L), constituyendo 98% del potasio corporal total (PCT), Su concentración plasmática varía entre 3,5 – 5 mEq/L. A diferencia del sodio, puede variar su concentración
http://www.cornealdystrophyfoundation.org Email: ExecDir@cornealdystrophyfoundation.org Focus on Education – Inspiration - Vision How I Came to Have Two Different Transplants By Deloris Axelrod I had been nearsighted (myopic) from childhood and had worn glasses to correct that. At the time of my transplants, my vision still tested at 20/40 and 20/30 corrected with glasses. I did