Orthodontic Acquaintance Card Date _____________ Patient’s Name_________________________ Birthdate ____________________Age ____________ Address __________________________________________________________________________ Home Phone_______________Height______Weight ______ Referred by _____________________ Cell Phone________________ Email___________________________________________________ Patient’s Dentist ___________________________ Patient’s Physcian ________________________ Spouse’s Name ___________________________ Home Phone ____________________________ Person Responsible for Financial Obligation _______________________ SS# _________________ Employer ________________________________ Address ________________________________ Occupation ______________________________ Telephone _______________________________ Is your orthodontic treatment covered in part by Insurance?______ Ins. Co.____________________ Address _________________________________________ Phone __________________________ Dental Date of last check up ____________ Any facial or Dental injuries?__________________________ Please describe ____________________________________________________________________ Any baby or permanent teeth removed by your dentist ? ___________________________________ Any thumb or finger sucking habit ?_________ Until what age ? __________________________ Any difficulty breathing through the nose (awake or asleep)? _______________________________ Any tooth clenching and/or grinding ? _________ Any clicking or pain when opening or closing the mouth? ___________________________ Any speech problems?____________________________ Do you smoke?________________________How long?___________________________________ Medical Are you currently under the care of a physician? _____________ If so, Why? ___________________ Are you taking any medication now? _________________ If so, What? _______________________ Are you currently taking or have been given intravenous bisphosphonates for serious bone cancers, such as Zometa or Aredia? Yes or No Are you currently taking or have been given oral or intravenous bisphosphonates for osteoporosis, osteopenia, or other uses, such as Fosamax, Actonel, Boniva, Reclast, Skelid, Didronel or Bonefos? Yes or No Any allergies or drug sensitivity? _____________________ If so, What?_______________________ Have tonsils and /or adenoids been removed ?___________ What age? ________ Please describe any Present or past medical problem ________________________________________________________ Hospitalization and operations _________________________________________________________ General What concerns you most about your teeth and facial appearance? _____________________________ __________________________________________________________________________________ Have other family members had orthodontic treatment? _____ In our office? ____________________ Name _________________________ Does anyone in your family have a similar dental problem?____________________________________ Do you have children?________ Your children’s names and date of birth____________________________________________________ ____________________________________________________________________________________ Signature __________________________________ E-Mail Address _________________________________________________
Address: Department of Clinical Oncology, Alexandria University Hospitals, Alexandria, Egypt. Current Job: Associate Professor, Department of Clinical Oncology, Alexandria University School of Medicine, Alexandria, Egypt. Previous Job: Fellow, Department of Radiation Oncology, Stanford University Medical Center, Stanford, CA, USA. Medical Career: Medical School Alexandr
Les propriétaires forestiers visitent une entreprise certifiée PEFC par Mieke Vercruijsse, PEFC Belgium S pécialisée dans la construction d’ossatures en bois, l’entreprise Mobic SA de Harzée bénéficie de la certification PEFC depuis un an et demi. Le 8 mai dernier, la Société Royale Forestière de Belgique y organisait une visite. Une vingtaine de propri�