Microsoft word - health history 2010 - edited .doc

1. Are you currently being treated by your physician for any medical condition? ____________________ ________________________________________________________________________________ 2. Physician’s Name _________________________________ 3 .Please list ALL medications you are currently taking: ______________________________________ _________________________________________________________________________________ 4. Please circle any illness you have ever had: heart valve replacement high blood pressure joint replacement allergies to medicine heart murmur heart trouble infectious hepatitis sinus problems mitral valve prolapse anemia tuberculosis asthma rheumatic fever diabetes epilepsy/seizures AIDS (HIV) psychological glaucoma kidney/liver thyroid Crohn's disease irritable bowel/colitis TMJ/TMD 5. Has a dentist or a physician ever told you that you need to take antibiotics before dental appointments for a medical condition ? No …. Yes … If yes, have you taken them today? No…. Yes…. What did you take?___________________ How much?____________ 6. Have you had knee, hip or other joint replacement? No… Yes ……. If so, when?_______________ 7. Have you ever taken any diet drugs such as Pondimin (fenfluramine), Redux (dexphenfluramine) or Phen-fen (fenfluramine-phentermine combination)? No… Yes…. If so, when? ___________ Have you seen your physician about this? No… Yes…… If so, when ?___________ 8. Do you wear a pacemaker? No…. Yes…. 9. Have you ever had trouble with prolonged bleeding after surgery? No…. Yes…. 10 . Do you take blood thinners such as Plavix (clopidoqrel), Coumadin (warfarin), Asprin ? N o… Yes. 11. Are you currently taking or have you taken bisphophonate medications, such as Actonel, Fosamax or Zometa, within the past 12 years? No…. Yes……. If so, which one? _______________ 12. Please circle any of the medications or substances listed below to which you have had an unusual reaction: Penicillin Clindamycin (Cleocin) Ibuprofen/Advil/Motrin Codeine Latex Aspirin Adrenaline (Epinephrine) Tylenol Sulfa Novocaine Erythromycin Others : please list below _____________________________________________________________________________ 12. Is there any other information that we should be know about your health? Any chronic conditions? ____________________________________________________________________________ 13. Is there any information that you would like to tell us about previous dental appointments? _______________________________________________________________________________ I certify that the above information is correct to the best of my knowledge. I understand that providing incorrect information can be dangerous to my health. I will not hold Endodontic Associates, LTD or any members of their dental team responsible for errors or omissions that I have made in completion of this form It is my responsibility to notify my dentist of any changes in the above medical status. Patient or Responsible Party Signature:____________________________________________ Date:______________________ Attending Doctor:_______________________________


Microsoft word - lm4-smo-96013_四校_.doc

J. Environ. Eng. Manage., 19(5), 277-282 (2009) ELECTRO-FENTON DEGRADATION OF SYNTHETIC DYE MIXTURE: INFLUENCE OF INTERMEDIATES Vahid Vatanpour,* Nezamaddin Daneshvar and Mohammad Hossein Rasoulifard Water and Wastewater Treatment Research Laboratory Key Words: Electrochemical advanced oxidation processes (EAOPs), malachite green, orange II, hydroquinone-like intermediates, wast

Proceedings of the 1st international workshop on electronic voting

From Legal Principles to an Internet Voting System German Research Center for Artificial Intelligence GmbH Abstract: Past research on Internet voting has been concentrated on two aspects. First, there are investigations to find the appropriate balance between anonymity and authentication. Second, the impact of the use of Internet voting to legislation has been studied. In this paper we a

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