Medical history

Last____________________First_______________ Date_______ 321-751-7775
1. Are you experiencing any medical problem now? ______________________________________________________
2. Are you currently taking any medications, drugs, pills, or nutritional supplement? Please list ____________________ _____________________________________________________________________________________________ 3. Are you currently or have you ever taken bisphosphonates (ex: Fosamax, Didronel, Aredia)? ____________________ 4. Are you allergic or have you reacted adversely to: (check those that apply)  Metals, if so which ______________________  Other _____________________________________ 5. Please describe your general health:  Excellent  Good  Fair  Poor 6. Do you use any tobacco products?  No  Yes If yes, what and how much per day?________________________ 7. Name of your Physician:_________________________________________ Phone No.________________________ 8. Have you been hospitalized in the past 5 years? If yes, please explain._____________________________________ _____________________________________________________________________________________________ PLEASE CHECK ANY OF THE FOLLOWING WHICH YOU HAVE HAD OR HAVE AT PRESENT:

Heart Failure
Radiation Therapy
Liver disease
Heart disease or Attack
Blood Transfusion
Angina Pectoris
Kidney Trouble
(Cancer, Leukemia)
Drug Addiction
High Blood Pressure
Heart Murmur
Venereal Disease
Rheumatic Fever
Cortisone or Steroid
Cold Sore/Fever Blisters
Congenital Heart Lesions
Active Tuberculosis (TB)
Epilepsy or Seizures
Mitral Valve Prolapse
Fainting or Dizzy Spells
Artificial Heart Valve
Hay Fever
Pain in Jaw Joints
Heart pacemaker
Sinus Trouble
HIV Positive (AIDS)
Psychiatric Treatment
Heart surgery
Allergies or Hives
Hepatitis A (Infectious)
Sickle Cell Disease
Joint (Hip, Knee)
Hepatitis B (serum)
Bruise or bleed easily
Thyroid Disease
Hepatitis C
Cosmetic Surgery
Patient signature:
1. What type of dental care are you most interested in? 6. Have you had dental treatment recommended to you that you haven’t completed? If so, why not? _________  Maintenance Care (patchwork treatment) _________________________________________  Incremental Care (developing and prioritizing a long  Complete Care (optimal treatment without delay)  Fillings  Extractions  Root Canals  Caps or Crowns  Fixed Bridges  Removable Bridges  Treatment of gum disease  Dentures  Implants  2. When did you last have dental treatment?________ Orthodontics  Cosmetic Bonding or Laminates  TMJ What was done?____________________________ Bite Adjustment  Other: ________________________ Name of dentist:____________________________ 8. Please check the following that are applicable: Due to HIPAA privacy regulations, you must request
 Teeth are sensitive to hot, cold, or pressure x-ray transfer yourself. Please ask for instructions.
 Gums bleed at times  Food wedges between teeth 3. Why are you seeking dental care now?__________ _________________________________________ 4. Are you having discomfort or complaints at this time? If so, please explain:_________________________  No  Slightly  Moderately  Very 5. If you could change anything about your mouth, what would that be? _____________________________ 10. What can we do to help you be more comfortable?____ ______________________________________________ _________________________________________________



BAY TRUST OPOTIK MOTU CHALLENGE MULTISPORT EVENT 10th October, 2009 Team Name City/Town ENTRIES - INDIVIDUAL - (OM-OF-VM-VF-MC) Team Name City/Town ENTRIES - TWO PERSON TEAM (OM2-OF2-MX2-VT2) John Morton &Simon Hunter & John Morton & Simon HunterSimon Blincoe & Rob Mountford & Rob Mountford & Simon BlincoeKatherine Allan & Donna Maxwell & Donn

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