PATIENT NAME ____________________________________________ DATE___________________ Primary reason for this dental appointment Examination Emergency Consultation Dental History
D Do you have a specific dental problem? __________________________________________________________________
Do you have dental examinations on a routine basis? Last visit_______________________________________________
Do you think you have active decay or gum disease?_______________________________________________________
Do you brush and floss on a routine basis?__________________________________________________________________
Do your gums ever bleed? Discuss__________________________________________________________________________
Do you like your smile? Why________________________________________________________________________________
Does food catch between your teeth?Any loose teeth?_____________________________________________________
Do you want to keep your remaining teeth?________________________________________________________________
Do you ever have clicking, popping or discomfort in the jaw joint?___________________________________________
Have your past experiences in a dental office always been positive?________________________________________
Do you smoke or chew? Any sores or growths in your mouth? Discuss________________________________________
Name of Previous Dentist(optional)_________________________________________________________________________
Date of last full mouth x-rays (16 small films or panoramic):___________________________________________________
Are you under a physician’s care now?Why_________________________________________________________________
Have y Have you ever been hospitalized or had a major operation? Discuss _________________________________________
Have you ever had a serious injury to your head or neck? Discuss____________________________________________
Are you taking any medications, pills or drugs? What?_______________________________________________________
Are you on a special diet? Discuss__________________________________________________________________________
Are you allergic to any medications or substances? Please check below _____________________________________
Aspirin Penicillin Codeine Acrylic Metal Latex Rubber Other ________________________
Have you ever taken bisphosphanate medication(such as Actonel, Aredia, Boniva, Fosamax, Zometa,
Bonefos, Ostac, Skelid, Didronel) ___________________________________________________________________________
Do you now have or have you ever had any of the following? Please check appropriate boxes.
*If yes to any of the starred conditions, please call prior to your appointment… premedication may be required
Have you ever had any other serious illness not checked above? Discuss ________________________________________Yes No Do you wish to talk to the dentist privately about any problem? __________________________________________________Yes No To the best of my knowledge, all of the preceding answers are correct. If I have any changes in my health status or if my medicines change, I shall inform the dentist and staff at the next appointment without fail. X ________________________________________________________________________________ Date _____________________________
PATIENT SIGNATURE(PARENT OR GUARDIAN) Reviewed by Doctor______________________________________________________________ Date ______________________________ History Review and Significant Findings: ________________________________________________________________________________ ______________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________
UNIVERSIDAD NACIONAL DE CÓRDOBA FACULTAD DE CIENCIAS QUÍMICAS DEPARTAMENTO DE FARMACIA C I M E CENTRO DE INFORMACIÓN SOBRE MEDICAMENTOS Ciudad Universitaria (5000) Córdoba - Tel: 351-4334127/ 63 int 110 Fax: 351-4334127 - E-mail: [email protected] DATOS DEL SOLICITANTE: FICHA N º: F116-07 NOMBRE: AURELIO F. GARCÍA ELORRIO FECHA: 5/09/07 Hora: DI
PSA UsedIf pre-biopsy not present, use presenting PSA38% had presenting PSA on GP letterPre-biopsy always Hosp 1Presenting PSA mixture of Hosp 1 and GPDo we need Hosp no for pre-biopsy PSA?Should presenting PSA be Hosp OR GP?Is this data useful?Recommendation: PSA value to be on study db as numeric value to ease analysis. Co-morbiditiesList attached. Can these be further categorised?Diagnosis an