3.1 KiB
3.1 KiB
type, category, person, date, provider, source
| type | category | person | date | provider | source |
|---|---|---|---|---|---|
| medical | oral surgery | Xuewei Jiang | 2016-10-18 | Midtown Oral & Maxillofacial Surgery | 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 |
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