Files

Yanxin Lu 637601a27c vault backup: 2026-04-05 16:20:12

2026-04-05 16:20:12 -07:00

8.7 KiB

Raw Blame History

type, category, person, date, provider, source

type	category	person	date	provider	source
medical	oral surgery	Xuewei Jiang	2016-10-18	Midtown Oral & Maxillofacial Surgery	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
Not Hispanic or Latin
Refuse to Report

Race

American Indian or Alaska Native
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
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
1)
2)
3)
4)
5)
6)
7)
8)

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.