To our patients: Although we primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems
you may have or medication that you may be taking may have an important bearing in the care that you wil be receiving. Thank you for
assisting us in providing you with the best possible care, by answering the fol owing questions. Your answers wil remain confidential. Are you in good health? YES NO Height_____________ Weight_____________ Date of last physical exam _____________ Have there been any changes in your general health in the last your? YES NO. Are you under the care of a physician for any condition(s)? YES NO Date of last visit:____________________________ If yes. for what condition(s) are you being treated? _____________________________________________________ ____________________________________________________________________________________________________ Have you been hospitalized or had any surgery in the past five years? YES NO Date of hospitalization: __________ Reason for hospitalization _______________________________________________________________________________________________ Have you ever taken prescription medication for weight reduction (diet pil s)? YES NO Are you currently taking, or have you ever taken any of the fol owing medications for the treatment of osteoporosis or cancer? Fosamax (alendronate) Actonel (risedronate) Boniva (ibandronate) Ske lid (tilud ronate) Didronel (etidronate) Aredia (pamidronate) Zometa (zoledronic acid) NO
prosthetic (artificial) joint replacement pain or clicking of the jaw joints (TMJ) Patient: ____________________________________


Are you currently taking
Are you allergic to, or have you ever
any of the following medications?
had a reaction to any of the following?
anticoagulants (blood thinners) including aspirin barbiturates, sedatives, or sleeping pil s WOMEN: Is there ANY possibility you may be pregnant? IS THERE ANY OTHE RCONDITION CONCERNING YOUR HEALTH OF WHICH THE DOCTOR SHOULD BE AWARE? YES NO
If yes, please explain_________________________________________________________________________________________________
Primary Care Physician
Telephone:________________________________ Telephone:________________________________ Telephone:________________________________ Telephone:________________________________ I hereby certify that I have read and understand the above. I acknowledge that my questions, if any, about the above health history questionnaire have been answered to my satisfaction. I wil not hold my surgeon or any members of his staff responsible for any errors or omissions that i may have made in the completion of this form. Signature of Patient:___________________ Date_________________ Reviewed________________ UPDATE___________________CHANGES_________________________________________________________________________________ UPDATE___________________CHANGES_________________________________________________________________________________ UPDATE___________________CHANGES_________________________________________________________________________________ Doctor’s Notes: _____________________________________________________________________________________________ ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Source: http://www.eonclinics.com/doc/medical_history.pdf


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Criteria for the allocation of the tfi-tÜv proficert-product brand - v3-1 valid from 2012-10-0

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