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REASON FOR VISIT: List in order of importance to you.
List any allergies to medications and / or foods
you are taking NOW. Include herbs, prescriptions, over-the-counter drugs, and vitamins.
CURRENT SYMPTOMS: Do you have any of the following symptoms? Please complete ALL
, how often? (circle one)
OTHER SYMPTOMS NOT LISTED:
IMMUNIZATIONS & TESTS:
What vaccinations do you know you have received in the past as an adult OR child? Check & provide date.
I have received my childhood vaccinations in the U.S. YES
Have you ever had a positive TB skin test? NO / YES If yes
, Chest X-ray result: Normal Abnormal
Have you ever been treated for TB? NO / YES
, date of treatment:
Length of treatment: _________months.
PAST MEDICAL HISTORY:
Do you have, or have you ever
had in the past, any of the following conditions?Check each box “yes” or “no”. No straight lines please. Complete ALL.
Does food or floss catch between your teeth?
Have you had periodontal (gum) treatments?
How do you feel about your smile?Date of last dental exam:
Are you taking or scheduled to begin taking alendronate (Fosamax®) OR risedronate (Actonel®)
Since 2001, were you treated or are you presently scheduled to begin treatment with the intravenousbisphosphonates (Aredia® or Zometa® ) for bone pain, hypocalcaemia or skeletal complicationsresulting from Paget's disease, multiple myeloma or metastatic cancer?
, date treatment began:
Has a physician/dentist recommended that you take antibiotics prior to your dental treatment?
, name of physician/dentist:
Do you have any other disease, condition or problem that you think I should know about?
PREVIOUS SURGERIES OR HOSPITALIZATIONS:
Has any of your family / blood relatives ever had any of the following?
SEXUAL HISTORY: Check one
Yes, had sexual activity in the past year.
Last sexual relations was ______ months/years ago.
Sexually active with (Check all that apply
): Men Women Both Paid for sex or ProstituteDoes your sexual partner have other sexual partners? No Yes I don’t know / maybeHave you had a sexual partner who has had sex with:
Have you OR your sexual partner(s) had any infections related to sex? No Yes, specify:Birth Control method you use now OR have used in the past: (Check all that apply)
Have any birth control methods caused you problems? No Yes, explain:What method of birth control are you using currently?
Age of first period?
Maximum # pads / tampons used in 24 hours?
Did your mother take D.E.S. (a hormone) when she was pregnant with you? NO / YES / UnknownREPRODUCTIVE HISTORY:
Have you ever been pregnant? NO / YES
Do you need assistance for DAILY ACTIVITIES?
Do you exercise regularly? NO / YES If yes, type and frequency (min. per day / week):
Do you have, or have you ever had, an eating disorder or special eating problems? NO / YES
, please explain:
Current Dietary Intake:
ANNUAL EXAM (HISTORY UPDATE AND REVIEW):
This form was completed on:
Friend / Relative: (Name / Relation)
NOTE: Provider and patient are encouraged to discuss all relevant patient health issues prior to treatment.
I certify that I have read and understand the above and that the information given on this form is accurate. I under-stand the importance of a truthful health history and that my doctor/dentist will rely on this information for treatingme. I acknowledge that my questions about inquiries set forth above have been answered to my satisfaction. I willnot hold my medical or dental provider or any member of the staff responsible for any action they take or do not takebecause of errors or omissions that I may have made in the completion of this form.
David, Joseph and Kathyrn, with respect to the RESULT: For respondents. death by suicide of their father, Mark S., 50. Decedent suffered depression when his wife, EXPERT TESTIMONY: Mace Beckson, Shanna S. left him, and as a result of his minor M.D., testified that it was below the standard daughter’s developmental disabilities, alleged of care to prescribe Effexor to a patient with to be the
elcome to the fifth issue of The NUFA NEWS . NUFA— the Nipissing University Faculty Association—consists of all full-time and contract academic staff. The NUFA News is one of the ways A new round of negotiations is just around the corner , so S as we did in the fourth issue, we’ve listed the members of NUFA’s Executive and the Bargaining Committees so that you can see who w