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Patient name _______________________________________ date __________
PATIENT NAME _______________________________________ DATE __________
Primary reason for this dental appointment Examination Emergency Consultation
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______________________________________________________________
Would you like to replace any missing teeth? _________________________________________________
Do you want to keep remaining teeth? _______________________________________________________
Do you ever have clicking, popping, or discomfort in the jaw joint? ________________________________
Do you have any mercury fillings or dental work that you don’t like? _______________________________
If money were no object, what improvements would you make in your smile? ________________________ Date of last full mouth x-rays: ______________________________________________________________ Medical History Are you under a physician’s care now? Why?__________________________________________________
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 allergic to any
medications or substances? Please check below_____________________________
Have you ever
taken bisphosphanate medication (such as Actonel, Aredia, Boniva, Fosamax, Bonefos, Ostac, Skelid, Didronel) Yes No
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
Hepatitis A (infectious) Y N
Artificial Heart Valve*
Heart Pace Maker*
Have you ever had any other serious illness not checked above? Discuss: _______________________
Do you with to talk to the dentist privately about any problems? ______________________________
I certify that I have read and understand the questions above. I acknowledge that my questions, if any, about the inquires set forth above have been answered to my satisfaction. I will not hold my dentist, or any other member of his/her staff, responsible for any errors or omissions that I have made in the completion of this form. Signature of patient: (Parent or Guardian if minor) ___________________________
I authorize my dentist and his/her designated staff to perform an oral examination, for the purpose of diagnosis and treatment planning. Furthermore, I authorize the
taking of all x-rays required as a necessary part of this exam. In addition, if medically necessary, I authorize the release pf any authorization acquired in the course of
my examination and treatment.
Signature of patient (Parent or Guardian if minor) ______________________________
ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES
I hereby acknowledge that a copy of this office’s Notice of Privacy Practices has been made available to me. I have been given the opportunity to ask any questions I
may have regarding this Notice.
Signature of patient: (Parent or Guardian if minor) ________________________________ Date: ______________________
Original Contribution JAMA. 1996;275(5):370-375. doi: 10.1001/jama.1996.03530290040035 Effects of Hormone Replacement Therapy on Endometrial Histology in Postmenopausal Women The Postmenopausal Estrogen/Progestin Interventions (PEPI) Trial 1. Writing Group for the PEPI Trial; 2. Howard L. Judd, MD; 3. Irma Mebane-Sims, PhD; 4. Claudine Legault, PhD; 5. Carol Wasilauskas, MS; 6. Susa
Rubem Braga, Antônio Bôto e o Vernéculoser famoso. Era um grande poeta, assim qualifi-cado pelos melhores críticos e, entre nós, pordo-me a passar uma temporada com ele. Manuel Bandeira. Grande poeta, também, paraseu amigo íntimo e confidente Fernando Pessoa,da vida. “Nada, nada de novo, rien de rien ”,que publicou na sua editora (dele, Pessoa), aescrevia, citando Edith Piaf.