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
HAVE YOU EVER HAD, OR DO YOU CURRENTLY HAVE:
prosthetic (artificial) joint replacement
pain or clicking of the jaw joints (TMJ)
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
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
THE JOHN MCKAY REPORT Member of Parliament Scarborough-Guildwood Volume 17 Issue 1 FLU SEASON 2009 - EXTRA CARE FOR YOUR FAMILY This is the time of year when one or more family members begin to cough and sneeze, have a high temperature and generally feel miserable. We call it “the flu” and usually let it run its course. However a new strain, H1N1, has emerged all
Criteria for the allocation of the TFI-TÜV PROFiCERT-product brand General requirements for the substances used . 2 3.1.1 Testing for consumer health protection . 3 3.1.2 Functional tests and quality tests for floor coverings. 6 Test criteria for underlays for instal ation and flooring installation products . 8 3.2.1 Testing for consumer health protection . 8 3.2.2 Functional