Patient profile
SYDNEY ORAL MEDICINE
YOUR DETAILS (Please print clearly)
Title. . . . . . . . . .Surname………………………Given Names…………………….…….
Date of birth………….……………………………. Gender: □ Male □ Female
Address………………………………………………………………………………….…
Suburb……………………………….State……………Postcode….….…
Telephone:.(H)………………………………….(M)………………………………………
(B)………………………………………Occupation.
Email……………………………………………………………………………………….
NEXT OF KIN/PERSON TO CONTACT IN EMERGENCY
Name:………………………………….Relationship to patient………………………….
PRIVATE HEALTH INSURANCE & MEDICARE
Do you have Private Health Insurance
with Dental cover? □ Yes □ No
Medicare card no…………………………….Ref.no………………Expiry date…………
Person responsible for accounts (if not self)……………………………………………….
Are you happy for us to confirm your appointments via SMS on your
mobile?
If not, would you prefer: □ Email □ Phone
Referring Doctor:
.
YOUR MEDICAL HISTORY
Please tick “Yes” if you have now, or have had in the past, any of the following:
Heart condition or murmur □ Yes □ No Muscle, bone, joint problems □ Yes □ No
Rheumatic fever □ Yes □ No Immune system problems □ Yes □ No
High blood pressure □ Yes □ No Gastrointestinal problems □ Yes □ No
Bleeding problems □ Yes □ No Urogenital problems □ Yes □ No
Respiratory problems □ Yes □ No Liver problems □ Yes □ No
Nervous system problems □ Yes □ No Cancer □ Yes □ No
Thyroid problems □ Yes □ No Pregnancy □ Yes □ No
Diabetes □ Yes □ No Smoking □ Yes □ No
Infectious diseases □ Yes □ No Alcohol □ Yes □ No
Osteoporosis □ Yes □ No Betel nut use □ Yes □ No
Medications…………………………………………………………………………………
………………………………………………………………………………………………
Have you ever been prescribed any of the following medications? Zometa™,
Pamidronate™, Bonefos™, Actonel™, Fosamax™ .
Hospital admissions……………………………………………………………………….
………………………………………………………………………………………………
Allergies…………………………………………………………………………………….
.…………………………………………………………………………………………….
Other…………………………………………………………………………………….…
FAMILY DOCTOR’S DETAILS
Doctor’s Name…………………………………………………………………………….
Address…………………………………………………………………………………….
Telephone………………………………………………………………………………….
Source: http://www.sydneyoralmedicine.com.au/som-patient-profile-medical-history.pdf
MISA DE SANTA JUANA DE LESTONNAC EN LA CLAUSURA DE LOS ACTOS DEL IV CENTENARIO DE LA FUNDACIÓN DE LA ORDEN MONICIÓN DE ENTRADA: Celebramos hoy el aniversario de la muerte de Sta Juana; su vida larga en años, y pródiga en obras, es una existencia generosa, rebosante, como la medida asegurada del evangelio de Lucas. Es la historia de una elección y una fidelidad. De una alianza (LLA
VINCENZO ROCHIRA Ricercatore Universitario Confermato SSD MED/50 Endocrinologia, Centro Nalin , Largo del Pozzo 71 Modena IGIENE DENTALE Breve Curriculum Vitae Laurea in Medicina e Chirurgia nel 1994 presso l’Università di Modena, specializzazione in Endocrinologia e Malattie del Ricambio presso l'Universita' di Modena nel 1999, Dottorato di Ricerca in Scienze Endocrino-Metabol