vault backup: 2026-04-05 16:20:12
This commit is contained in:
Yanxin Lu
BIN
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documents/medical/oral_surgery/201610181224191000.md
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|
||||
---
|
||||
type: medical
|
||||
category: oral surgery
|
||||
person: Xuewei Jiang
|
||||
date: 2016-10-10
|
||||
provider: Midtown Oral & Maxillofacial Surgery
|
||||
source: 201610181224191000.jpg
|
||||
---
|
||||
|
||||
# Midtown Oral & Maxillofacial Surgery
|
||||
|
||||
**H. Paul Casmedes, D.D.S., M.D. / Ann H Kristovich, D.D.S.**
|
||||
Suite 410
|
||||
Board Certified, American Board of Oral & Maxillofacial Surgery
|
||||
|
||||
901 West 38th Street,
|
||||
Austin, TX 78705
|
||||
|
||||
---
|
||||
|
||||
**Patient Type:** New Patient
|
||||
|
||||
**Pediatrician / Primary Care Doctor:**
|
||||
**Referring Physician:** Dr. Mary Becher
|
||||
|
||||
**Date:** 10/10/2016
|
||||
|
||||
---
|
||||
|
||||
## PATIENT INFORMATION
|
||||
|
||||
| Field | Value |
|
||||
|---|---|
|
||||
| Patient's Last Name | Jiang |
|
||||
| First | Xuewei |
|
||||
| Middle | |
|
||||
| Age | 23 |
|
||||
| Sex | Female |
|
||||
| Date of Birth | 03/13/1993 |
|
||||
| Street Address | 1652 W 6st Apt R |
|
||||
| Social Security No. | 092-99-3215 |
|
||||
| Primary Phone Number | (254) 214-1350 |
|
||||
| City | Austin |
|
||||
| State | TX |
|
||||
| ZIP Code | 78703 |
|
||||
| Secondary Phone Number | (254) 224-1457 |
|
||||
|
||||
### Ethnicity
|
||||
|
||||
- [ ] Hispanic or Latin
|
||||
- [x] Not Hispanic or Latin
|
||||
- [ ] Refuse to Report
|
||||
|
||||
### Race
|
||||
|
||||
- [ ] American Indian or Alaska Native
|
||||
- [x] Asian
|
||||
- [ ] Native Hawaiian
|
||||
- [ ] Black or African American
|
||||
- [ ] White
|
||||
- [ ] Hispanic
|
||||
- [ ] Other Race
|
||||
- [ ] Other Pacific Islander
|
||||
|
||||
| Field | Value |
|
||||
|---|---|
|
||||
| Primary Parent / Guardian Name | |
|
||||
| Email | |
|
||||
| Social Security No. | |
|
||||
| Daytime Phone | |
|
||||
| Date of Birth | |
|
||||
| Employer | |
|
||||
| Employer phone No. | |
|
||||
| Second Parent / Guardian Name | |
|
||||
| Marital Status of Parents | Married |
|
||||
|
||||
### Emergency Contact
|
||||
|
||||
| Field | Value |
|
||||
|---|---|
|
||||
| In case of emergency, please contact | Yanxin Lu |
|
||||
| Phone Number | (254) 224-1457 |
|
||||
| Relation | Spouse |
|
||||
|
||||
---
|
||||
|
||||
## INSURANCE INFORMATION
|
||||
|
||||
### Primary Insurance
|
||||
|
||||
| Field | Value |
|
||||
|---|---|
|
||||
| Type | Dental |
|
||||
| Name of Primary Insurance | Delta Dental |
|
||||
| Subscriber's Name | Xuewei Jiang |
|
||||
| Subscriber's S.S. # | 092-99-3215 |
|
||||
| Subscriber's Date of Birth | 03/13/1993 |
|
||||
| Subscriber's Sex | Female |
|
||||
| Policy No. | V17NK34D |
|
||||
| Group No. | 5968 |
|
||||
| Group Name | |
|
||||
| Subscriber Address | |
|
||||
| Patient's relationship to subscriber | Self |
|
||||
| City | Austin |
|
||||
| State | TX |
|
||||
| ZIP Code | 78703 |
|
||||
|
||||
### Secondary Insurance
|
||||
|
||||
| Field | Value |
|
||||
|---|---|
|
||||
| Name of Secondary Insurance | Blue Cross Blue Shield |
|
||||
| Subscriber's Name | Xuewei Jiang |
|
||||
| Subscriber's S.S. # | 092-99-3215 |
|
||||
| Subscriber's Date of Birth | 03/13/1993 |
|
||||
| Policy No. | V17NK34D |
|
||||
| Group No. | 071778 |
|
||||
| Group Name | |
|
||||
| Subscriber Address | |
|
||||
| Patient's relationship to subscriber | Self |
|
||||
|
||||
Page 1 of 1
|
||||
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documents/medical/oral_surgery/201610181224191001.md
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documents/medical/oral_surgery/201610181224191001.md
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|
||||
---
|
||||
type: medical
|
||||
category: oral surgery
|
||||
person: Xuewei Jiang
|
||||
date: 2016-10-18
|
||||
provider: Midtown Oral & Maxillofacial Surgery
|
||||
source: 201610181224191001.jpg
|
||||
---
|
||||
|
||||
# HEALTH HISTORY
|
||||
|
||||
| Field | Value |
|
||||
|---|---|
|
||||
| City | |
|
||||
| State | |
|
||||
| ZIP Code | |
|
||||
| Patient Name (Last) | Jiang |
|
||||
| Patient Name (First) | Xuewei |
|
||||
| Date | 10/18/2016 |
|
||||
|
||||
To our patients: Although oral surgeons primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have or medication that you may be taking could have an important interrelationship with the care that you will be receiving. Thank you for answering the following questions. Your answers are for our records only and will be considered confidential.
|
||||
|
||||
---
|
||||
|
||||
## General Questions
|
||||
|
||||
| Question | Answer |
|
||||
|---|---|
|
||||
| Are you under the care of a physician? | Yes |
|
||||
| Date of last visit? | Grimes, Jill MD |
|
||||
| Has anyone in your family ever been seen by Dr. Casmedes? | No |
|
||||
| If so, who? | |
|
||||
| Are you in good health? | Yes |
|
||||
| Height | 5'5 |
|
||||
| Weight | 132 lb |
|
||||
| Have you had any illness, operation or been hospitalized in the past five year? | No |
|
||||
| If yes, please describe | |
|
||||
| What are your concerns regarding today's office visit? | Extraction for orthodontic treatment |
|
||||
|
||||
---
|
||||
|
||||
## Medical History Checklist
|
||||
|
||||
### Have you had or do you currently have...
|
||||
|
||||
| Condition | Yes | No | Notes |
|
||||
|---|---|---|---|
|
||||
| Rheumatic Fever | | x | |
|
||||
| Damaged heart valves? | | x | |
|
||||
| Mitral valve prolapse? | | x | |
|
||||
| Heart murmur? | | x | |
|
||||
| Heart valve replacement? | | x | |
|
||||
| High or low blood pressure | | x | |
|
||||
| Chest pain (angina)? | | x | |
|
||||
| Heart attack(s)? | | x | |
|
||||
| Irregular heart beat | | x | |
|
||||
| Pacemaker? | | x | |
|
||||
| | | | |
|
||||
| Heart Surgery? | | x | |
|
||||
| Swelling of feet or ankles? | | x | |
|
||||
| Bronchitis? | | x | |
|
||||
| Asthma? | | x | |
|
||||
| Tuberculosis? | | x | |
|
||||
| Emphysema? | | x | |
|
||||
| Other lung trouble? | | x | |
|
||||
| Blood disorder (anemia)? | | x | |
|
||||
| Blood transfusion? | | x | |
|
||||
| Bruise easily? | | x | |
|
||||
| Abnormal bleeding? | | x | |
|
||||
| Hepatitis or other liver disease? | | x | |
|
||||
| Fainting spells? | | x | |
|
||||
| Epilepsy or seizures | | x | |
|
||||
| Stroke? | | x | |
|
||||
| High Cholesterol? | | x | |
|
||||
|
||||
| Condition | Yes | No | Notes |
|
||||
|---|---|---|---|
|
||||
| Kidney trouble? | | x | |
|
||||
| Diabetes? | | x | |
|
||||
| Are you on dialysis? | | x | |
|
||||
| Thyroid problems? | | x | |
|
||||
| Arthritis or joint disease? | | x | |
|
||||
| Prosthetic joint replacement? | | x | |
|
||||
| Osteoporosis/osteopenia? | | x | |
|
||||
| Osteonecrosis of any bones? | | x | |
|
||||
| History of immunosuppression? | | x | |
|
||||
| Problems with your immune system? | | x | |
|
||||
| Sexually transmitted diseases? | | x | |
|
||||
| AIDS or HIV infection? | | x | |
|
||||
| History of cancer? | | x | |
|
||||
| Chemotherapy or radiation? | | x | |
|
||||
| Chronic fatigue or night sweats? | | x | |
|
||||
| Drug or alcohol abuse? | | x | |
|
||||
| Eating disorder? | | x | |
|
||||
| Eye disease/glaucoma? | | x | |
|
||||
| Do you wear contacts? | | x | |
|
||||
| Mental health problems? | | x | |
|
||||
| Pain or clicking of the jaws when eating? | | x | |
|
||||
| A removable dental appliance? | | x | |
|
||||
| Do you smoke? (If yes, how many packs per day?) | | x | |
|
||||
| Do you consume alcohol? (If yes, how much and how often?) | | x | |
|
||||
|
||||
Page 2 of 3
|
||||
307
documents/medical/oral_surgery/oral surgery form xuewei.md
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307
documents/medical/oral_surgery/oral surgery form xuewei.md
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@@ -0,0 +1,307 @@
|
||||
---
|
||||
type: medical
|
||||
category: oral surgery
|
||||
person: Xuewei Jiang
|
||||
date: 2016-10-18
|
||||
provider: Midtown Oral & Maxillofacial Surgery
|
||||
source: oral surgery form xuewei.pdf
|
||||
---
|
||||
|
||||
# Midtown Oral & Maxillofacial Surgery
|
||||
|
||||
**H. Paul Casmedes, D.D.S., M.D. / Ann H Kristovich, D.D.S.**
|
||||
Suite 410
|
||||
Board Certified, American Board of Oral & Maxillofacial Surgery
|
||||
|
||||
901 West 38th Street,
|
||||
Austin, TX 78705
|
||||
|
||||
---
|
||||
|
||||
**Patient Type:** New Patient
|
||||
|
||||
**Pediatrician / Primary Care Doctor:**
|
||||
**Referring Physician:** Dr. Mary Becher
|
||||
|
||||
**Date:** 10/10/2016
|
||||
|
||||
---
|
||||
|
||||
## PAGE 1: PATIENT INFORMATION
|
||||
|
||||
| Field | Value |
|
||||
|---|---|
|
||||
| Patient's Last Name | Jiang |
|
||||
| First | Xuewei |
|
||||
| Middle | |
|
||||
| Age | 23 |
|
||||
| Sex | Female |
|
||||
| Date of Birth | 03/13/1993 |
|
||||
| Street Address | 1652 W 6st. Apt. R |
|
||||
| Social Security No. | 092-99-3215 |
|
||||
| Primary Phone Number | (254) 214-9350 |
|
||||
| City | Austin |
|
||||
| State | TX |
|
||||
| ZIP Code | 78703 |
|
||||
| Secondary Phone Number | (254) 224-1457 |
|
||||
|
||||
### Ethnicity
|
||||
|
||||
- [ ] Hispanic or Latin
|
||||
- [x] Not Hispanic or Latin
|
||||
- [ ] Refuse to Report
|
||||
|
||||
### Race
|
||||
|
||||
- [ ] American Indian or Alaska Native
|
||||
- [x] Asian
|
||||
- [ ] Native Hawaiian
|
||||
- [ ] Black or African American
|
||||
- [ ] White
|
||||
- [ ] Hispanic
|
||||
- [ ] Other Race
|
||||
- [ ] Other Pacific Islander
|
||||
|
||||
| Field | Value |
|
||||
|---|---|
|
||||
| Primary Parent / Guardian Name | |
|
||||
| Email | |
|
||||
| Social Security No. | |
|
||||
| Daytime Phone | |
|
||||
| Date of Birth | |
|
||||
| Employer | |
|
||||
| Employer phone No. | |
|
||||
| Second Parent / Guardian Name | |
|
||||
| Marital Status of Parents | Married |
|
||||
|
||||
### Emergency Contact
|
||||
|
||||
| Field | Value |
|
||||
|---|---|
|
||||
| In case of emergency, please contact | Yanxin Lu |
|
||||
| Phone Number | (254) 224-1457 |
|
||||
| Relation | Spouse |
|
||||
|
||||
---
|
||||
|
||||
### INSURANCE INFORMATION
|
||||
|
||||
#### Primary Insurance
|
||||
|
||||
| Field | Value |
|
||||
|---|---|
|
||||
| Type | Dental |
|
||||
| Name of Primary Insurance | Delta Dental |
|
||||
| Subscriber's Name | Xuewei Jiang |
|
||||
| Subscriber's S.S. # | 092-99-3215 |
|
||||
| Subscriber's Date of Birth | 03/13/1993 |
|
||||
| Subscriber's Sex | Female |
|
||||
| Policy No. | V17NK34D |
|
||||
| Group No. | 5968 |
|
||||
| Group Name | |
|
||||
| Subscriber Address | |
|
||||
| Patient's relationship to subscriber | Self, Spouse |
|
||||
| City | Austin |
|
||||
| State | TX |
|
||||
| ZIP Code | 78703 |
|
||||
|
||||
#### Secondary Insurance
|
||||
|
||||
| Field | Value |
|
||||
|---|---|
|
||||
| Type | Medical |
|
||||
| Name of Secondary Insurance | Blue Cross Blue Shield |
|
||||
| Subscriber's Name | Xuewei Jiang |
|
||||
| Subscriber's S.S. # | 092-99-3215 |
|
||||
| Subscriber's Date of Birth | 03/13/1993 |
|
||||
| Subscriber's Sex | Female |
|
||||
| Policy No. | V17NK34D |
|
||||
| Group No. | 071778 |
|
||||
| Group Name | |
|
||||
| Subscriber Address | |
|
||||
| Patient's relationship to subscriber | Self |
|
||||
|
||||
Page 1 of 3
|
||||
|
||||
---
|
||||
|
||||
## PAGE 2: HEALTH HISTORY
|
||||
|
||||
| Field | Value |
|
||||
|---|---|
|
||||
| City | |
|
||||
| State | |
|
||||
| ZIP Code | |
|
||||
| Patient Name (Last) | Jiang |
|
||||
| Patient Name (First) | Xuewei |
|
||||
| Date | 10/18/2016 |
|
||||
|
||||
To our patients: Although oral surgeons primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have or medication that you may be taking could have an important interrelationship with the care that you will be receiving. Thank you for answering the following questions. Your answers are for our records only and will be considered confidential.
|
||||
|
||||
### General Questions
|
||||
|
||||
| Question | Answer |
|
||||
|---|---|
|
||||
| Are you under the care of a physician? | Yes |
|
||||
| Date of last visit? | Grimes, Jill MD |
|
||||
| Has anyone in your family ever been seen by Dr. Casmedes? | No |
|
||||
| If so, who? | |
|
||||
| Are you in good health? | Yes |
|
||||
| Height | 5'5 |
|
||||
| Weight | 132 lb |
|
||||
| Have you had any illness, operation or been hospitalized in the past five year? | No |
|
||||
| If yes, please describe | |
|
||||
| What are your concerns regarding today's office visit? | Extraction for orthodontic treatment |
|
||||
|
||||
### Medical History Checklist
|
||||
|
||||
| Condition | Yes | No | Notes |
|
||||
|---|---|---|---|
|
||||
| Rheumatic Fever? | | x | |
|
||||
| Damaged heart valves? | | x | |
|
||||
| Mitral valve prolapse? | | x | |
|
||||
| Heart murmur? | | x | |
|
||||
| Heart valve replacement? | | x | |
|
||||
| High or low blood pressure? | | x | |
|
||||
| Chest pain (angina)? | | x | |
|
||||
| Heart attack(s)? | | x | |
|
||||
| Irregular heart beat? | | x | |
|
||||
| Pacemaker? | | x | |
|
||||
| Heart Surgery? | | x | |
|
||||
| Swelling of feet or ankles? | | x | |
|
||||
| Bronchitis? | | x | |
|
||||
| Asthma? | | x | |
|
||||
| Tuberculosis? | | x | |
|
||||
| Emphysema? | x | | |
|
||||
| Other lung trouble? | | x | |
|
||||
| Blood disorder (anemia)? | | x | |
|
||||
| Blood transfusion? | | x | |
|
||||
| Bruise easily? | | x | |
|
||||
| Abnormal bleeding? | | x | |
|
||||
| Hepatitis or other liver disease? | | x | |
|
||||
| Fainting spells? | | x | |
|
||||
| Epilepsy or seizures? | | x | |
|
||||
| Stroke? | | x | |
|
||||
| High Cholesterol? | | x | |
|
||||
| Kidney trouble? | | x | |
|
||||
| Diabetes? | | x | |
|
||||
| Are you on dialysis? | | x | |
|
||||
| Thyroid problems? | | x | |
|
||||
| Arthritis or joint disease? | | x | |
|
||||
| Prosthetic joint replacement? | | x | |
|
||||
| Osteoporosis/osteopenia? | | x | |
|
||||
| Osteonecrosis of any bones? | | x | |
|
||||
| History of immunosuppression? | | x | |
|
||||
| Problems with your immune system? | | x | |
|
||||
| Sexually transmitted diseases? | | x | |
|
||||
| AIDS or HIV infection? | | x | |
|
||||
| History of cancer? | | x | |
|
||||
| Chemotherapy or radiation? | | x | |
|
||||
| Chronic fatigue or night sweats? | | x | |
|
||||
| Drug or alcohol abuse? | | x | |
|
||||
| Eating disorder? | | x | |
|
||||
| Eye disease/glaucoma? | x | x | |
|
||||
| Do you wear contacts? | | x | |
|
||||
| Mental health problems? | | x | |
|
||||
| Pain or clicking of the jaws when eating? | | x | |
|
||||
| A removable dental appliance? | | x | |
|
||||
| Do you smoke? (If yes, how many packs per day?) | | x | |
|
||||
| Do you consume alcohol? (If yes, how much and how often?) | | x | |
|
||||
|
||||
Page 2 of 3
|
||||
|
||||
---
|
||||
|
||||
## PAGE 3: MEDICATIONS & ALLERGIES
|
||||
|
||||
**Patient Name (Last):** Jiang
|
||||
**Patient Name (First):** Xuewei
|
||||
|
||||
### Is the patient taking or has ever taken:
|
||||
|
||||
(Y = Yes, N = No)
|
||||
|
||||
| Medication/Substance | Yes | No |
|
||||
|---|---|---|
|
||||
| Blood thinners (Coumadin, Aspirin, Advil) | | x |
|
||||
| History of eating disorder? | | x |
|
||||
| Diet pills | | x |
|
||||
| Any bone density medication or Bisphosphonates (Aredia, Zometa, Fosamax, Actonel) | | x |
|
||||
| Pain killers (including aspirin) | | x |
|
||||
| Tranquilizers | | x |
|
||||
| Muscle relaxers | | x |
|
||||
| Insulin | | x |
|
||||
| Stimulants | | x |
|
||||
| Antidepressants | | x |
|
||||
|
||||
### Is the patient allergic to, or had a reaction to:
|
||||
|
||||
(Y = Yes, N = No)
|
||||
|
||||
| Allergen | Yes | No |
|
||||
|---|---|---|
|
||||
| Penicillin | | x |
|
||||
| Sulfa drugs | | x |
|
||||
| Other antibiotics | | x |
|
||||
| Valium or other tranquilizers | | x |
|
||||
| Codeine or other narcotics | | x |
|
||||
| Local anesthetic (numbing medicine) | | x |
|
||||
| Aspirin/Motrin/Ibuprofen/Tylenol | | x |
|
||||
| Latex | | x |
|
||||
| Soy or any egg products? | | x |
|
||||
| I have no known allergies | x | |
|
||||
|
||||
**Please list any other medications the patient is allergic to:**
|
||||
(none listed)
|
||||
|
||||
### Medication List
|
||||
|
||||
| # | Medication | Dosage | Frequency |
|
||||
|---|---|---|---|
|
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| 1) | | | |
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| 2) | | | |
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| 3) | | | |
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| 4) | | | |
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| 5) | | | |
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| 6) | | | |
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| 7) | | | |
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| 8) | | | |
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|
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---
|
||||
|
||||
### Certification
|
||||
|
||||
I **certify** that I have read and I understand the questions above. I acknowledge that my questions, if any, about the inquiries set forth above have been answered to my satisfaction. I will not hold my surgeon, or any other member of his/her staff, responsible for any errors or omissions that I have made in the completion of this form.
|
||||
|
||||
**Signature of patient:** Xuewei (signed)
|
||||
(parent or guardian if minor)
|
||||
**Physician Reviewed:**
|
||||
**Date:** 10/18/2016
|
||||
|
||||
**Print Name:** Xuewei Jiang
|
||||
|
||||
---
|
||||
|
||||
### FEES AND PAYMENTS
|
||||
|
||||
We make every effort to keep down the cost of your oral surgical care. You can help by paying upon completion of each visit. Other arrangements can be made with our office manager. An estimate of the charge for any procedure or surgery you may require will be given to you upon request. If you have dental and/or medical insurance we will be glad to fill out the proper forms, but please complete the identifying information on this form.
|
||||
|
||||
Please remember that insurance is considered a method of reimbursing the patient for fees paid to the doctor and is not a substitute for payment. Some companies pay fixed allowances for certain procedures and others pay a percentage of the charge. **It is your responsibility to pay any deductible amount, co-insurance or any other balance not paid for by your insurance company.** You will be responsible for all collection costs, attorney's fees, and court costs.
|
||||
|
||||
**Signature of patient:** Xuewei (signed)
|
||||
(parent or guardian if minor)
|
||||
**Reviewed by:**
|
||||
**Date:** 10/18/2016
|
||||
|
||||
---
|
||||
|
||||
### AUTHORIZATION
|
||||
|
||||
I **authorize** my surgeon and his/her staff, to perform an oral and maxillofacial examination, for the purpose of diagnosis and treatment planning. Furthermore, I authorize the taking of all x-rays required as a necessary part of this examination. In addition, if medically necessary, I authorize the release of any information acquired in the course of my examination and treatment.
|
||||
|
||||
**Signature of patient:** Xuewei (signed)
|
||||
(parent or guardian if minor)
|
||||
**Reviewed by:**
|
||||
**Date:** 10/18/2016
|
||||
|
||||
Page 3 of 3
|
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Reference in New Issue
Block a user