Mais les résultats doivent être attendus longtemps et il n'y a généralement pas de temps metronidazole prix L'autre cas, c'est que l'achat d'un ou d'un autre antibiotique dans une pharmacie classique nécessite des dépenses matérielles considérables et pas toutes les personnes ne peuvent acheter des produits pharmaceutiques aussi coûteux.

Patient-form-adult

American Association of Orthodontists
MEDICAL DENTAL HISTORY FORM – ADULT
Patient's Last Name: ___________________________ First Name: _____________________________ I Prefer To Be Called: _______________________ S.S.N./S.I.N.: _______________ Home Phone No.: ( E-mail address: ___________________________________________ Cell phone number: ____________________ Pager number:____________________ Patient's Address: _____________________________________________________________________________ If less than 5 years at current address, previous address:___________________________________________________________________________________ Employer:________________________________ Name Of Spouse/Closest Relative: ________________________________ Relationship To You: __________________________ Address (if different than yours): _____________________________________________________________________________ Name Of Patient's Dentist: ___________________________________ Dentist's Address: ____________________________________________________________________________________ Reason: _________________________________________________ Name Of Patient's Physician(s): _________________________________________ Physician's Address: _______________________________________________________________________ Reason: __________________________________________ Who suggested that you might need orthodontic treatment? _____________________________ Why did you select our office? ____________________________________________________ Who Is Financially Responsible For This Account? Last Name: ________________________________ Address (if different than patient’s)______________________________________________________________________ City: ______________________________________ Insurance Coverage For Dental Treatment? Yes Insurance Coverage For Orthodontic Treatment? Yes Primary Policy Holder's Name: _____________________________________________-_______________ Employed By: __________________________________________________________ Dental Insurance Company: _________________________________________________________ Secondary Policy Holder's Name: __________________________________________ S.S.N./S.I.N.: _______________________________ Employed By: __________________________________________________________ Dental Insurance Company: _____________________________________________ Medical Insurance Company: ______________________________ or the following questions mark yes, no, or don't know/understand (dk/u). The answers are for office records only and will be
considered confidential. A thorough and complete history is vital to a proper orthodontic evaluation.
MEDICAL HISTORY
Now or in the past, have you had:
dk/u Are you currently taking or have you ever taken any
intravenous bisphosphonates for serious bone dk/u Birth defects or hereditary problems?
disorders/cancers: such as Zometa (zolendronic acid), Aredia dk/u Bone fractures, any major accidents?
dk/u Rheumatoid or arthritic conditions?
dk/u Are you currently taking or have you ever taken any oral
dk/u Endocrine or thyroid problems?
bisphosphonates for osteoporosis, osteopenia or other uses: such as Fosamax (alendronate), Actonel (risendronate), dk/u Kidney problems?
Boniva (ibandronate) Skelid (tiludronate), Didronel dk/u Diabetes?
dk/u Cancer, tumor, radiation treatment or chemotherapy?
dk/u Are you taking medication, nutrient supplements, herbal
dk/u Stomach ulcer or hyperacidity?
medications or non prescription medicine? Please name them. dk/u Polio, mononucleosis, tuberculosis, pneumonia?
dk/u Problems of the immune system?
dk/u AIDS or HIV positive?
dk/u Hepatitis, jaundice or liver problem?
dk/u Fainting spells, seizures, epilepsy or neurological problem?
dk/u Mental health disturbance or depression?
dk/u Vision, hearing, tasting or speech difficulties?
dk/u Loss of weight recently, poor appetite?
dk/u History of eating disorder (anorexia, bulimia)?
dk/u Excessive bleeding or bruising tendency, anemia or
dk/u Do you currently have or ever had a substance abuse
dk/u High or low blood pressure?
dk/u Do you chew or smoke tobacco?
dk/ u Tired easily?
dk/u Operations? Describe: _______________________
dk/u Chest pain, shortness of breath or swelling ankles?
dk/u Hospitalized? For: __________________________
dk/u Cardiovascular problem (heart trouble, heart attack, angina,
dk/u Other physical problems or symptoms? Describe: _______
coronary insufficiency, arteriosclerosis, stroke, inborn heart defects, heart murmur or rheumatic heart disease)? dk/ u Being treated by another health care professional?
dk/u Skin disorder?
Date of most recent physical exam? __________________ dk/u Do you have a well-balanced diet?

Do you have any other medical conditions that we should know about?
dk/u Frequent headaches, colds or sore throats?
________________________________________________________ dk/u Eye, ear, nose or throat condition?
dk/u Hayfever, asthma, sinus trouble or hives?
WOMEN ONLY
dk/u Tonsil or adenoid conditions?
dk/u Osteoporosis?
dk/u Are you pregnant?
dk/u Are you anticipating becoming pregnant?
Allergies or reactions to any of the following:
dk/u Local anesthetics (Novocaine or Lidocaine)
FAMILY MEDICAL HISTORY
dk/u Aspirin
Do your parents or siblings have, or have ever had any of the following dk/u Ibuprofen (Motrin, Advil)
dk/u Penicillin or other antibiotics
Bleeding disorders________________________________________________ dk/u Sulfa drugs
Diabetes________________________________________________________ dk/u Codeine or other narcotics
Arthritis________________________________________________________ dk/u Metals (jewelry, clothing snaps)
Severe allergies__________________________________________________ dk/u Latex (gloves, balloons)
Unusual dental problems___________________________________________ dk/u Vinyl
Jaw size imbalance________________________________________________ dk/u Acrylic
Any other family medical conditions that we should know about? ___________ dk/u Animals
dk/u Foods (specify) ___________________________________
dk/u Other substances (specify) __________________________
DENTAL HISTORY
dk/u Any pain or soreness in the muscles of the face or around
Now or in the past, has the patient had:
dk/u Permanent or "extra" (supernumerary) teeth removed?
dk/u Difficulty in chewing or jaw opening?
dk/u Supernumerary (extra) or congenitally missing teeth?
dk/u Have you ever been treated for "TMD" or "TMJ" problems?
dk/u Chipped or otherwise injured primary (baby) or permanent
dk/u Aware of loose, broken or missing restorations (fillings)?
dk/u Any teeth irritating cheek, lip, tongue or palate?
dk/u Teeth sensitive to hot or cold; teeth throb or ache?
dk/u Concerned about spaced, crooked or protruding teeth?
dk/u Jaw fractures, cysts or mouth infections?
dk/u Aware or concerned about under or over developed jaw?
dk/u "Dead teeth" or root canals treated?
dk/u Any relative with similar tooth or jaw relationships?
dk/u Bleeding gums, bad taste or mouth odor?
dk/u Any wisdom tooth problems?
dk/u Periodontal "gum problems"?
dk/u Had periodontal (gum) treatment?
dk/u Food impaction between teeth?
dk/u Had any serious trouble associated with any previous dental
dk/u "Gum boils", frequent canker sores or cold sores?
dk/u Thumb, finger, or sucking habit? Until what age ________?
dk/u Been under another dentist's care?
Specialist _______________________________ dk/u Abnormal swallowing habit (tongue thrusting)?
Other __________________________________ dk/u History of speech problems?
dk/u Ever had a prior orthodontic examination or treatment?
dk/u Mouth breathing habit, snoring or difficulty in breathing?
dk/u Would you object to wearing orthodontic appliances
dk/u Tooth grinding or jaw clenching?
dk/u Any pain, clicking or locking in jaw or ringing in the ears?

How often do you brush:
What is your primary concern? Why are you here? __________________________________________________________________ Questions: ___________________________________________________________________________________________________________________________ DOCTOR CONTACT INFORMATION
Doctor's Last Name: _____________________________ E-mail address: ____________________________________________ Doctor's Address: _____________________________________________________________________________ City: _______________________________________ I have read and understand the above questions. I will not hold my orthodontist or any member of his/her staff responsible for any errors or omissions that I have made in the completion of this form. If there are any changes later to this history record or medical/dental status, I will so inform this practice. Signed: ______________________________________________________ Date Signed: ________________ (Patient) Signed: ______________________________________________________ Date Signed _________________ (Dental staff member) MEDICAL HISTORY UPDATE OR CHANGES
Comments: _______________________________________________________________________________ Signed: ______________________________________________________ Date Signed: ________________ (Patient) Signed:_______________________________________________________ Date Signed: _______________ (Dental Staff Member) MEDICAL HISTORY UPDATE OR CHANGES
Comments: ______________________________________________________________________________

Signed: ______________________________________________________ Date Signed: ________________
(Patient)
Signed:_______________________________________________________ Date Signed: _______________
(Dental Staff Member)
MEDICAL HISTORY UPDATE OR CHANGES
Comments: ______________________________________________________________________________

Signed: ______________________________________________________ Date Signed: ________________
(Patient)
Signed:_______________________________________________________ Date Signed: _______________
(Dental Staff Member)
MEDICAL HISTORY UPDATE OR CHANGES
Comments: _______________________________________________________________________________
Signed: ______________________________________________________ Date Signed: ________________
(Patient)
Signed:_______________________________________________________ Date Signed: _______________
(Dental Staff Member)
American Association of Orthodontists 2003

Source: http://www.chadwellsmiles.com/docs/patient-form-adult.pdf

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