PATIENT’S NAME _________________________________________________ BIRTHDAY ________/________/________ AGE__________ ADDRESS___________________________________________________________HOME PHONE______________________________________ CITY________________________ STATE________ ZIP_________________CELL PHONE_______________________________________ EMPLOYER/OCCUPATION____________________________________________WORK PHONE______________________________________ DENTAL INSURANCE PLAN (if any)________________________________________________________________________________________ And WHOM MAY WE THANK FOR THIS REFERAL?___________________________________________________ We would like to say thanks! ________________________________________________________________________________________________________________________ DENTAL HISTORY ——————————————————————————————————————————————————————–————-— FORMER DENTIST_____________________________________________________ DATE OF LAST EXAM_____________________________ WHAT CONCERNS YOU ABOUT YOUR TEETH?_____________________________________________________________________________ RATE YOURSELF ABOUT DENTAL VISITS: ___________ Calm __________ A bit nervous __________ Very nervous DENTAL HISTORY: ________Periodontal Treatment ________Orthodontic Treatment ___________Frequency Brushing __________Flossing ________________________________________________________________________________________________________________________ MEDICAL HISTORY ——————————————————————————————————————————————————–———–—————––
PHYSICIAN’S NAME___________________________________ PHONE__________________________ DATE OF LAST VISIT_____________ ARE YOU PRESENTLY UNDER A PHYSICIAN’S CARE? ____________Yes ___________No If YES, please explain ______________________________________________________________________________________________________ HAVE YOU EVER HAD A SERIOUS ILLNESS/ OPERATION, OR STILL HAVE ONE? _____________Yes ____________No If YES, please explain ______________________________________________________________________________________________________ ARE YOU TAKING ANY MEDICATIONS OR SUPPLEMENTS? _______________Yes ____________No If YES, please list _________________________________________________________________________________________________________ DO YOU HAVE ANY ALLERGIES TO MEDICATIONS OR DRUGS? _____Yes _____No If YES, list: ________________________________ HAVE YOU EVER TAKEN BONE DRUGS? (Fosamax, Evista, Actonel, Boniva, Reclast, others) _____________________Yes __________No CHECK ANY THAT APPLY: ___________Allergies to Anesthetics ______Artificial Joints ______Artificial Heart Valve _______Hepatitis _____High Blood Pressure _________Cancer ________Heart Problems _____Liver or Kidney Problems _____Tobacco Use ____Tuberculosis ________Immune Problems ________Bleeding Problems ____HIV Positive ____Taking Contraceptives ____Latex Allergy ______Diabetes ____Now Pregnant ________ Psychiatric or Emotional Problems ____Other, please explain____________________________________________ Thank you for choosing our office for your dental care!
I CERTIFY THAT THE ABOVE IS COMPLETE & ACCURATE:
Signature_____________________________________________________________ Date________/________/_______
Drivers’ Contents Chapter 1 Personal Preparation Chapter 2 Equipment a. Clothing b. Helmets d. Ear Protection Chapter 3 The Working Environment b. Padding c. Ventilation d. Supplementary Comfort Chapter 4 Safety Harnesses Chapter 5 On an Event a. All Events b. Race Events c. Rally Events d. Rally Safety