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Microsoft word - vwfamdent_pt_medical_history

E-mail Address:____________________________________________ Name: _________________________________________ I prefer to be called: _____________ ◊ Male ◊ Female Last First Mi Mr Mrs Ms Dr Birthdate: ___/___/___ Social Security #:______-______-______ ◊ Single ◊ Married ◊ Divorced ◊ Widowed ◊ Separated Home Address: ___________________________________________________________________________________________ Street City State Zip Home Phone: (_____)_____________ Cell Phone: (_____)____________ Work Phone: (_____)____________ Ext:________ Where & when are the best times to reach you? ______________________________ Whom may we thank for referring you? _________________________ Other Family members seen by us: _____________________________________________________________________________________________________ Employer: _____________________________________ Occupation: _______________________________________________ Employer’s Address: _______________________________________________________________________________________ Street/PO Box City State Zip His/ Her Name: __________________________________ Birthdate:____/_____/____ Social Security #: _____-_____-_____ Employer: _________________________________________________ Work Phone: (_____)_________________ Ext:_______ His/ Her Name: ________________________ Relation:____________ Work Phone:(____)____________ Home Phone: (____)____________ Address: _____________________________________________________________________________________________________________ Street/PO Box City State Zip Primary Dental Insurance Insurance Co. Name: _____________________________ Phone: (____)____________ Group#: _________________________ Insurance Co. Address: _____________________________________________________________________________________ Street/PO Box City State Zip Insured’s Name: ___________________ Insured’s Social Security: __________________ Insured’s Birthdate: _____/_____/_____ Relation: _____________ Insured’s Employer: _________________________ Employer’s Address: ________________________________________________________ Street/PO Box City State Zip Secondary Dental Insurance Insurance Co. Name: _____________________________ Phone: (____)____________ Group#: _________________________ Insurance Co. Address: _____________________________________________________________________________________ Street/PO Box City State Zip Insured’s Name: ___________________ Insured’s Social Security: __________________ Insured’s Birthdate: _____/_____/_____ Relation: _____________ Insured’s Employer: _________________________ Employer’s Address: ________________________________________________________ Street/PO Box City State Zip Are you currently in pain? ◊ Yes ◊ No Are your teeth sensitive to heat, cold, or anything else? _______________________ Do you require antibiotics before dental treatment? ◊ Yes ◊ No Do you have any loose teeth? ◊ Yes ◊ No Your Current dental health is ◊ Good ◊ Fair ◊ Poor Do you still have wisdom teeth? ◊ Yes ◊ No Previous/Present Dentist:____________ Last Visit Date:________ Type of bristles on your toothbrush? ◊ Hard ◊ Medium ◊ Soft Would you like fresher breath? ◊ Yes ◊ No Would you like whiter teeth? ◊ Yes ◊ No Have you ever had periodontal disease? ◊ Yes ◊ No Are you happy with the way your smile looks? ◊ Yes ◊ No Do you have a personal physician? ◊ Yes ◊ No Physician’s Name: _________________________________________ Phone: (______)_________________ Date of last visit: _____________ Are you currently under the care of a Medical Specialist? ◊ Yes ◊ No Please Explain: _______________________________________________________________________________________________________ Do you smoke or use tobacco in any other form? ◊ Yes ◊ No Have you ever taken Phen-Fen, Redux, or Pondimin? ◊ Yes ◊ No Have you ever taken Fosamax, or any other bisphosphonate? ◊ Yes ◊ No For Women: Are you taking birth control? ◊ Yes ◊ No Are you Pregnant? ◊ Yes ◊ No ◊ Unsure Please list any medical condition(s) that you have experienced: _____________________________________________________ Are you taking anything any prescription/ over the counter drugs? ◊ Yes ◊ No If Yes, Please list each one: ____________________________________________________________________________________________ Please list anything additional that causes allergic reactions: ________________________________________________________ I affirm that the information I have given is correct to the best of my knowledge, and that it is my responsibility to inform this office of any changes in my medical status. I authorize the dental staff to perform the necessary services I may need. I assign the Doctor all insurance benefits. I understand that I am responsible for payment of services rendered, any deductible, and co-payments that my insurance does not cover. I have received a copy of this office Notice of Privacy Practices. ________________________________________________________

Source: http://www.vwfamilydentistry.com/pdfs/vwfamdent_pt_medical_history.pdf

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Mary W. Bourke Profile Mary Bourke is a Partner in Womble Carlyle’s Intellectual Property Practice Group in the firm’s Wilmington, Delaware office. She represents clients in patent litigation related to biotechnology and pharmaceutical matters. Mary has over 25 years of patent litigation experience at both the district court and appellate levels. She has been involved in multiple

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1. Among 734 randomly selected Internet users, it was found that 340 of them use the Internet for making travel plans (based on data from a Gallup poll). Use a 0.01 significance level to test the claim that among Internet users, less than 50% use the Internet for making travel plans. (12 points) Reject H0 if T.S. is less than critical value -2.33 (table A) or if p-value is less than 0.01. p

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