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Cadillac oral and maxillofacial surgeons health history form

K.A. STEGMANN, D.D.S. • W.L. OLSEN, D.D.S. • C.H. FOUNTAIN, D.D.S. • D.C. MADION, D.D.S., M.D.
Today's Date __________________
NAME ______________________________________________________ Circle any of the following
whO REfERRED yOu tO OuR OfficE? ____________________________ NickNAME (if any) ____________________________________________ which pertain to you:
DENtiSt’S NAME _____________________________________________ ADDRESS ___________________________________________________ PhySiciAN’S NAME ___________________________________________ city _______________________________________________________ ORthODONtiSt’S NAME _______________________________________ StAtE __________________________ ZiP cODE____________________ whO AccOMPANiED yOu tO thE OfficE? _________________________ hOME PhONE (________) ______________________________________ iN thE EvENt Of AN EMERgENcy, whO ShOuLD wE cONtAct? cELL PhONE (________) _______________________________________ NAME ______________________________________________________ biRth DAtE ____________________ S.S.#_______________________ RELAtiONShiP _______________________________________________ AgE_______ SEx_______ (M/f) MARitAL StAtuS _____________ (M/S) wORk #______________________ hOME # ______________________ OccuPAtiON/buSiNESS NAME __________________________________ PAtiENt'S EMPLOyER __________________________________________ wORk # (________) __________________________________________ NAME ______________________________________________________ NAME Of PARENt OR SPOuSE (circle which) ________________________ RELAtiONShiP _______________________________________________ PARENt OR SPOuSE'S EMPLOyER ________________________________ ADDRESS ___________________________________________________ OccuPAtiON/buSiNESS NAME __________________________________ EMPLOyER __________________________________________________ wORk # (________) __________________________________________ PhONE # ___________________________________________________ hAvE yOu OR ANyONE iN yOuR fAMiLy bEEN OuR PAtiENt bEfORE? __________ S.S. # _____________________________________________________ NAME ______________________________________________________ bANkiNg iNStitutiON _________________________________________ _____ _____ hAvE yOu bEEN uNDER thE cARE Of A PhySiciAN fOR ANy SERiOuS iLLNESS? PLEASE LiSt. _______________________________ _____ _____ wAS yOuR LASt PhySicAL ExAM MORE thAN twO yEARS AgO? wOMEN: ARE yOu PREgNANt?_______ DO yOu SMOkE?_______ _____ _____ ARE yOu ALLERgic tO ANy MEDiciNES, LAtEx, EggS, SOy PRODuctS? _________________________________________________ _____ _____ DO MEDicAtiONS fOR PAiN RELiEf cAuSE NAuSEA? PLEASE LiSt. _____________________________________________________ _____ _____ hAvE yOu EvER hAD AN uNuSuAL REActiON tO DENtAL ANESthEtic? _____ _____ DO yOu tAkE OR hAvE yOu tAkEN ANy Of thE fOLLOwiNg MEDicAtiONS fOR OStEOPOROSiS OR bONE cANcER? (ciRcLE which) ActONEL / bONivA / fOSAMAx / fOSAMAx PLuS D / AREDiA / bONEfOS / ZOMEtA / REcLASt _____ _____ DO yOu hAvE ANy PRObLEMS with yOuR jAw jOiNtS? SNAPPiNg PAiN LiMitED OPENiNgLiSt ANy MEDiciNES yOu tAkE (iNcLuDiNg ANy ORAL cONtRAcEPtivES tAkEN) ________________________________________________________ _________________________________________________________________________________________________________________________ PRiMARy DENtAL iNSuRANcE cOMPANy ____________________________________________ SubScRibER __________________________________________________________________ DENtAL iNSuRANcE cOMPANy ___________________________________________________ ADDRESS _____________________________________________________________________ SubScRibER _________________________________________________________________ SubScRibER'S biRthDAtE _______________________________________________________ ADDRESS ____________________________________________________________________ SubScRibER'S S.S.# ____________________________________________________________ SubScRibER'S biRthDAtE ______________________________________________________ SubScRibER’S iNSuRANcE i.D. # __________________________________________________ SubScRibER'S S.S.# ___________________________________________________________ SubScRibER'S EMPLOyER ________________________________________________________ SubScRibER’S iNSuRANcE i.D. # _________________________________________________ _____________________________________________________________________________ SubScRibER'S EMPLOyER _______________________________________________________ gROuP NuMbER _______________________________________________________________ ____________________________________________________________________________ gROuP NuMbER ______________________________________________________________ PRiMARy MEDicAL iNSuRANcE cOMPANy ___________________________________________ SubScRibER __________________________________________________________________ do you have additional medical insurance? ADDRESS _____________________________________________________________________ MEDicAL iNSuRANcE cOMPANy _________________________________________________ SubScRibER'S biRthDAtE _______________________________________________________ SubScRibER _________________________________________________________________ SubScRibER'S S.S.# ____________________________________________________________ ADDRESS ____________________________________________________________________ SubScRibER’S iNSuRANcE i.D. # __________________________________________________ SubScRibER'S biRthDAtE ______________________________________________________ SubScRibER'S EMPLOyER ________________________________________________________ SubScRibER'S S.S.# ___________________________________________________________ _____________________________________________________________________________ SubScRibER’S iNSuRANcE i.D. # _________________________________________________ gROuP NuMbER _______________________________________________________________ SubScRibER'S EMPLOyER _______________________________________________________ please show insuranCe CarDs To The
____________________________________________________________________________ reCepTionisT so Copies Can be maDe.
gROuP NuMbER ______________________________________________________________ please remoVe CoaTs anD use laVaTorY
Signature _________________________________________Date_______________ (if necessary) beFore enTerinG TreaTmenT area.

Source: http://www.cadillacoralsurgeons.com/forms/Health-History-Form.pdf

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Chapter 5 Quiz Review November 19, 2008 Answer questions on another sheet of paper. 1. Canada requires that cars be equipped with “daytime running lights,” headlights that automatically come on at a low level when the car is started. Many manufacturers are now equipping cars sold in the United States with running lights. Will running lights reduce accidents by making cars more visible?

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