Health Information Patient Name: Have you experienced any of the following? Y N Angina/Chest Pain Frequent Cough Pain in Jaw Joints Breathing Problems Frequent Diarrhea Recent Weight Loss Bruise Easily Frequent Urination Sinus Problems Difficulty Swallowing Hives or Rash Swollen Joints Excessive Thirst Jaundice Fainting or Dizziness Nervousness Are you allergic to: Local anesthetic (Novocain/Xylocaine) Percodan Penicillin Nitrous Oxide Erythromycin Other: ______________ Tetracycline Have you ever had any of the following? Please check those that apply:
Y N AIDS (HIV+) Glaucoma/Eye Disease Radiation Treatment Allergies (Pollen Dust) Heart Attack/Failure Scarlet/Rheumatic Fever Alzheimer’s Disease Heart Murmur/Irregularity Sickle Cell Disease Hepatitis A / B / C Skin Disease Arthritis/Gout/Rheumatism Artificial Heart Valve High Blood Pressure Stomach Problems/ IBS Artificial Joints Hypoglycemia Intestinal Problems Kidney Problems Thyroid Disease Blood Disease Leukemia Transplant Cancer/Chemotherapy Liver Disease Tuberculosis Cold Sores Low Blood Pressure Tumors or Growths Congenital Heart Disorder Lung Disease Cortisone Medicine Migraines Diabetes Mitro Valve Prolapse ____________________________ Drug/Alcohol Addiction Orthodontics ____________________________ Dry Mouth Osteoporosis ____________________________ Emphysema/Lung Disease Periodontal Treatment Epilepsy or Seizures Psychiatric Care
Do you need to Pre-Medicate for your dental appointment? Yes No Have you had any previous dental complications? Yes No If yes, please explain______________________________________ Are you currently under the care of a physician? Yes No If yes, please explain_______________________________________ Have you been admitted to a hospital or needed emergency care during the past two years? Yes No If yes, please explain_________________________________________________________________________________________ Women: (please check) pregnant / trying to get pregnant Nursing Taking oral contraceptives Have you taken any supplements, tobacco, and alcohol or had significant weight loss in the last 3 months?______________________ List all current medications:_____________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ To the best of my knowledge, all the preceding answers and information provided are true and correct. If I ever have any change in my health, I will inform the doctor at the next appointment without fail. ________________________________________________________________________________ Date: ___________________ Signature of patient, parent or guardian Doctor: ________________________________________________________ Date:_____________ Patient BP: ____________
Researchers wanted to measure the effect of alcohol on the development of the hipppocampal region inadolescents. The hippocampus is th portion of the brain responsible for long-term memory storage. Theresearchers randomly selected 12 adolescents with alcohol use disorders. They wanted to test the claim thehippocampal volumes in the alcoholic adolescents were less than the normal volume of 9.02 c
SYRIAN ARAB REPUBLIC - MINISTRY OF ELECTRICITY PUBLIC ESTABLISHMENT FOR DISTRIBUTION AND EXPLOITATION OF ELECTRICAL E SYRIAN ARAB REPUBLIC MINISTRY OF ELECTRICITY PUBLIC ESTABLISHMENT FOR DISTRIBUTION AND EXPLOITATION OF ELECTRICAL ENERGY (PEDEEE) Three Phase ACTIVE AND REACTIVE ENERGY MULTI-FUNCTION, MULTI-TARIFF STATIC METERS 3x230/400 volt, X/5 Amp Approved