METRO-POINTE DENTAL
Patient Form (病人表格)
Name/姓名
Last Name (姓)
First Name (名字)
Gender/性别
Male/男性
Female/女性
Birthday/生日
-
Month
-
Day
Year
Date/日期
Address/家庭地址
Street Address/街道地址
Street Address Line 2/街道地址 2
City/城市
Province/省份
Postal Code/邮政编码
Best phone number to reach you at(可以联络您的电话号码)
-
Area Code (区号)
Phone Number (电话号码)
Email address(电邮地址)
Are you experiencing any of the following?(您是否遇到以下任何症状?)
Severe difficulty breathing (e.g. struggling to breathe or speaking in single words) (严重呼吸困难)
Severe chest pain (严重胸膛疼痛)
Having a very hard time waking up (起床非常困难)
Feeling confused (头脑纷乱)
Losing consciousness (失去意识)
Mild to moderate shortness of breath (呼吸急促 )
Inability to lie down because of difficulty breathing (因呼吸困难而不能躺下)
Chronic health conditions that you are having difficulty managing because of difficulty breathing (因呼吸困难而不能管理慢性病)
Fever (发烧)
Cough (咳嗽)
Sneezing (打喷嚏)
Sore Throat (喉咙痛)
None of the above (我没有任何症状)
What's your emergency? What kind of pain are you experiencing?(请描述您的症状/痛楚)
Please explain as much as possible. (请尽量描述)
How bad is the pain?(请自评您的痛楚)
1
2
3
4
5
Mild (轻微)
Severe (严重)
1 is Mild (轻微), 5 is Severe (严重)
Please upload a photo/xray of the situation if possible (如有X-ray片可以描述情况,请在这里上载)
Browse Files
This will help us with the diagnosis (这可以帮助我们的诊断)
Cancel
of
How did you hear about our office?(您是怎么听到我们的办公室? )
Online, word of mouth, referral? (网上,转介等等?)
Back
Next
Which area of the mouth is it causing you pain?(口腔是在哪里痛?)
Upper/上面
Lower/下面
Left/左边
Right/右边
Front/前面
Back/后面
Gums/牙龈
Have you TRAVELED outside of Canada in the past 14 days?(14日内您有没有离开过加拿大?)
Yes (有)
No (无)
Do you have a current medical problem?(您有没有慢性疾病?)
Yes (有)
No (无)
Are you taking any medication?(您现在有没有服用药品?)
Yes (有)
No (无)
Are you taking any of the following? Please select: (您有没有长期服用以下的药品?请选择/描述)
Advil/Ibuprofen (阿德维尔/布洛芬 )
Tylenol/Paracetamol(泰诺/扑热息痛)
Tylenol 3 - T3 (泰诺3【含可待因的泰诺】)
Antibiotics (抗生素)
Do you have any heart problems?(您有没有心脏问题?)
Yes (有)
No (无)
Do you have high or low blood pressure?(您有没有高/低血压?)
Yes, high blood pressure (有,高血压)
Yes. low blood pressure (有,低血压)
No (无)
Is your blood pressure controlled? (您的血压可收控制吗?)
Yes (有)
No (无)
Not sure (不清楚)
Do you ever have pains in your chest? (您的胸膛曾经有疼痛吗?)
Yes (有)
No (无)
Have you ever had any major operations? (您曾经有接受过大手术吗?)
No (否)
Yes, please explain: (如有,请描述)
Have you ever been involved in a serious accident? (您曾经于过严重的意外吗?)
No (否)
If Yes, please explain: (如有,请描述)
Do you bruise or bleed easily? (您會容易流血/青肿嗎?)
Yes (有)
No (否)
Do you smoke? (您抽烟嗎?)
No (否)
Yes, how many cigarettes a day? (有,每天多少次?)
Have you ever had any of the following conditions? (您曾經有以下的狀況嗎?)
hepatitis (肝炎)
sinusitis (鼻窦炎)
arthritis (关节炎)
diabetes (糖尿病)
epilepsy (癫痫)
anaemia (贫血)
asthma (哮喘)
ARC/AIDS (HIV) (艾滋病)
muscular dystrophy (肌肉萎缩症)
multiple sclerosis (多发性硬化症)
psychiatric care (精神科护理)
thyroid disease (甲狀腺疾病)
immune disorders (免疫疾病)
T.B. or lung disease (肺结核病 )
blood disorders (血病)
veneral disease (性病)
heart problem or stroke (心脏病/中风)
kidney or liver disease (肾/肝脏疾病)
gastrointestinal disease (肠胃疾病 )
abnormal blood pressure (血压异常)
rheumatic fever or heart murmur (风湿热/心脏杂音)
artificial joints or valves (人工关节/血管)
radiotherapy or chemotherapy (放疗/化疗)
mental or nervous disease (精神/神经疾病)
None of the above (我没有任何状况)
Have you ever had an allergy or an unusual reaction to: (您对以下的有敏感或不正常的反应吗?)
Penicillin (盘尼西林)
Aspirin (阿司匹林 )
Dental Anaesthetic (牙科麻醉剂)
Codeine (可待因 )
Milk Casein Protein (酪蛋白 )
Other medications (其他药物,请描述):
No allergies (没有过敏)
Have you been advised not to take medication? If Yes, what medication? (有没有人劝告您不应服用什么药品?如有,是什么药?)
We want to know if you have intolerance or interactions with certain medications (为了您的安全,我们想知道您会不会对某种药物有反抗作用/相互影响)
For WOMAN ONLY - are you pregnant? (仅限女性:您现在怀孕吗?)
We avoid taking x-rays during pregnancy!
Dental Insurance (牙科保险)
If we're able to check your coverage prior to appointment, we will do so on your behalf. Please fill out as best as you can. Please skip if you don't have insurance coverage. (如果我们找到您的保险资料,我们会帮您处理。请尽量填写您的保险资料。如没有保险,请略过。)
Insurance #1 (保险公司1)
Group #:
ID #:
Coverage (%) A:
Coverage (%) B:
Coverage (%) C:
Coverage (%) D:
Policy Holder's Name(保险持有者名字)
Birthdate (出生日期)
Fill out again - Just for confirmation for insurance submission
INSURANCE #2 (保险公司2)
Group #:
ID #:
Coverage (%) A
Coverage (%) B
Coverage (%) C
Coverage (%) D
POLICY HOLDER'S NAME(保险持有者名字)
BIRTHDATE (出生日期)
Permit of Operation: This is to certify that I, undersigned, consent to the performing of the dental and oral surgery procedures agreed to be necessary or advisable, including the use of general anaesthetic or local anesthetic as indicated and I assume responsibility for fees associated with those procedures. Patient's (legal guardian/parent's) signature is required below:
*
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