617 Riverside Avenue Burlington, VT 05401 Medical: (802) 864-6309 Fax: (802) 652-1056 Dental: (802) 652-1050 www.chcb.org

Staff Initials: ____________

Rev Jan2013 CRD

Patient Name: _______________________________________ Date of Birth: ______________ Date: _____________Please answer these questions as best you can. We want to know your special needs so we can give you the best care. Please check the answer that is right for you, “Yes”, “No”, “DK” (Don’t Know.) Your answers are confidential and for our records only. - - - - BLACK OR BLUE PEN ONLY - - - -

Dental Patient Medical History ForM

Yes No DK

Has there been a major change to your health within the past year? .......................................................................................

If yes, please explain: _________________________________________

Are you under the care of a physician or are you receiving ongoing medical care? ...................................................................

Name of your physician: _______________________________________

Physician’s Phone Number: ___________________________________

Date of your last medical visit: ___________________________________

Are you pregnant? ........................................................................ If Yes, due date: _____________________________________________

Do you breast feed? .....................................................................

Do you have any artificial joints, heart valves, implants, or prosthesis?...............................................................................

Have you ever been told you need to be pre-medicated priorto dental treatment? .....................................................................

Have you had surgery, x-ray treatment, or chemotherapy for atumor, growth, or other condition? ..................................................

If yes, please explain: _________________________________________

Please list all medications you are taking (Please include prescription and non-prescription medications):Medication: Dosage: How Often Taken: Reason for Medication:

1. ___________________________________________________________________________________________________________________

2. ___________________________________________________________________________________________________________________

3. ___________________________________________________________________________________________________________________

4. ___________________________________________________________________________________________________________________

5. ___________________________________________________________________________________________________________________

6. ___________________________________________________________________________________________________________________

7. ___________________________________________________________________________________________________________________

8. ___________________________________________________________________________________________________________________9. ___________________________________________________________________________________________________________________

Yes No DK

Are you having any dental discomfort at this time? ........................If yes, please explain: _________________________________________

Have you ever had serious trouble with previous dental work? ..... If yes, please explain: _________________________________________

Does dental work make you nervous? ...........................................

Have you ever had any abnormal bleeding associated withprevious extractions, surgery, or trauma? ..................................... If yes, please explain: _________________________________________

Date of your last dental visit: ____________________________________

How often do you brush your teeth? ______________________________

How often do you floss your teeth? _______________________________

Medical Dental

Medications Yes No DKAre you taking any prescription or over-the-counter medications?

Yes No DK

Do you use tobacco? ..............What? _______ How much _____

Do you use alcohol? ...............What? _______ How much _____

Do you have any CURRENT/PAST history of substance abuse? ..If yes, please explain: _________ __________________________________________________________

Other:Please check the answer that is right for you, “Yes”, “No”, “DK” (Don’t Know):

Allergies Yes No DKAre you allergic to anything? Please list all allergies including reaction:

Allergy to: Reaction:1. ___________________________________________________________________________________________________________________

2. ___________________________________________________________________________________________________________________

3. ___________________________________________________________________________________________________________________

4. ___________________________________________________________________________________________________________________Burmese

ဝနထမးအမည- ___________

သြားကနးမာေရး၊ လနာ၏ ေဆးကသမႈ မတတမး

617 Riverside Avenue Burlington, VT 05401 ေဆးကသမႈ- (802) 864-6309 ဖကစ- (802) 652-1056 သြားကနးမာေရး- (802) 652-1050 www.chcb.org

လနာအမည- ________________________________________________________________ ေမြးေန႔- _______________________________ ေန႔စြ- _______________________

ေအာကပါေမးခြနးမားက သငတတႏငသမ အေကာငးဆးေျဖဆပါ။ သငအား အေကာငးဆး ေစာငေရာကမႈေပးရနအတြက ကၽြႏပတ႔မ သင၏ အထးလအပခကမား လပါသည။

“ဟတသည” “မဟတပါ” “မသပါ” ဟ သငေလာေသာ အေျဖက ေျဖဆပါ။ သငအေျဖမားသည ကၽြႏပတ႔မတတမးတငရန အတြကသာျဖစၿပး လ႕ဝကထားရပါည။ - - - - မငအနက သ႔မဟတ အျပာကသာ အသးျပပါ - - - -

ေဆးကသမႈ သြားကနးမာေရး

ဟတသည မဟတပါ မသပါ

ၿပးခေသာ ႏစအတြငးတြင သငကနးမာေရးသည ႀကးမားေသာေျပာငးလမႈတစခ ရခပါသည? ...................................................................................................................................................

ရခပါက ရငးျပပါ - __________________________________________________________________________________

သငသည သမားေတာႏင ျပသေနရျခငး သ႔မဟတ လကရတြငေဆးကသမႈ ခယေနျခငး ရပါသလား? .....................

သမားေတာအမည - _________________________________________________________________________________

သမားေတာ၏ ဖနးနပါတ - _____________________________________________________________________________

ေနာကဆး ေဆးကသမႈ ခယခေသာေန႔စြ - __________________________________________________________________

သငတြင ကယဝနေဆာငထားပါသလား? ..........................................................................................

ေဆာငထားပါက ေမြးဖြားမညရကက ေဖာျပပါ - _____________________________________________________________

သငသည မခငႏ႔ တကေကၽြးပါသလား - ...........................................................................................

သငတြင အဆစအတ၊ ႏလးအဆ႔ရငအတ၊ အစားထးထညသြငးထားျခငးမား သ႔မဟတ ခႏၶာကယအစတပငး အတမား ရပါသလား?................................................................................................................

သြားကသမႈမျပမ အႀကေဆးကသမႈ ျပလပရနလသညဟ သငအား ေျပာၾကားဖးပါသလား? ................................

သငသည အကတ၊ ႀကးထြားမႈ သ႔မဟတ အျခားအေျခအေနတစရပအား ခြစတကသမႈ၊ x-ray ကသမႈ၊ သ႔မဟတ ေဆးသြငးကသမႈမား ခယထားဖးပါသလား? .............................................................................................

ရခပါက ရငးျပပါ - ___________________________________________________________________________________

ဟတသည မဟတပါ မသပါ

သငသည လကရတြင သြားျပနာ ရေနပါသလား? .................................................................................. ရပါက ရငးျပပါ - _____________________________________________________________________________________

ၿပးခသည သြားကသမႈတြင ျပနာျပငးထနစြာ ႀကခဖးပါသလား?.................................................................. ရပါက ရငးျပပါ - _____________________________________________________________________________________

သြားကသမႈက သငက စးရမစတျဖစေစပါသလား? .....................................................................................

ၿပးခေသာ သြားႏႈတျခငး၊ ခြစတျခငး သ႔မဟတ ဒါဏရာကသျခငးမား ျပလပစဥက သငသည ပမနမဟတသည ေသြးထြကျခငးက ႀကခဖးပါသလား? ......................................................................................................

ရပါက ရငးျပပါ - _____________________________________________________________________________________

ေနာကဆးအႀကမ သြားကသမႈ ျပလပခသည ေန႔စြ - ____________________________________________________________

တစေန႔လင ဘယႏႀကမ သြားတကသနညး? ________________________________________________________________

တစေန႔လင ဘယႏႀကမ သြားၾကားထးသနညး? ______________________________________________________________

အျခား- “ဟတသည” “မဟတပါ” “မသပါ” ဟ သငေလာေသာ အေျဖက ေျဖဆပါ-

ဟတသည မဟတပါ မသပါ

ေဆးလပႏင ေဆး႐ြကႀကးသးပါသလား? ................. အမးအစား? __________ ပမာဏ ___________________

ယမကာတစမးမ း ေသာကပါသလား? ................... အမးအစား? __________ ပမာဏ ___________________

မးယစေဆးဝါးႏင စတကေျပာငးလေစေသာ ေဆးမား လကရ/အတတ တြင သးစြပါသလား? ..................... ရပါက ရငးျပပါ -_________________________________

___________________________________________________________________________________________________________________________

ေဆးဝါးသးစြမႈ

ဆရာဝနေပးေသာေဆး သ႔မဟတ ေဆးဆငမဝယယေသာေဆးက လကရတြင သးစြေနပါသလား?ဟတသည မဟတပါ မသပါ

လကရ သငသးစြေနေသာ ေဆးအားလးက စာရငးျပစေဖာျပပါ (ဆရာဝနေပးေသာေဆး ႏင မမဖာသာဝယေသာေဆးမားက ေဖာျပပါ)- ေဆးဝါး - သးစြသညပစ - သးစြရမညအႀကမေရ - သးရသည အေၾကာငးအရငး -

1. ____________________________________________________________________________________________________________________

2. ____________________________________________________________________________________________________________________

3. ____________________________________________________________________________________________________________________

4. ____________________________________________________________________________________________________________________

5. ____________________________________________________________________________________________________________________

6. ____________________________________________________________________________________________________________________

7. ____________________________________________________________________________________________________________________

8. ____________________________________________________________________________________________________________________

9. ____________________________________________________________________________________________________________________

ဓာတမတညမႈ

သငသည တစခခႏင ဓာတမတညျခငး ရပါသလား?

ဟတသည မဟတပါ မသပါ

ဓာတမတညမႈမားအားလးႏင ၎တ႔၏ တ႔ျပနပက စာရငးျပစေရးသားပါ- ဓာတမတညသညအရာ- တ႔ျပနပ-

1. ____________________________________________________________________________________________________________________

2. ____________________________________________________________________________________________________________________

3. ____________________________________________________________________________________________________________________

4. ____________________________________________________________________________________________________________________

READ ONLY

Burmese

Rev Jan2013 CRD

Medical Information:Please check the answer that is right for you, “Yes”, “No”, “DK” (Don’t Know).

Patient Name: _______________________________________ Date of Birth: ______________ Date: _____________

I understand that, to the best of my knowledge, all of the proceeding answers are true and correct. If I ever have any change in my health or medications, I will inform my health care provider immediately. I hereby give my consent to treatment for myself, or the named patient (of whom I am the parent, legal guardian, or foster parent) to the Community Health Centers of Burlington.We set aside time just for you. If you’re running late or must change an appointment, please call us as soon as possible. Arriving late may require your provider to reschedule your visit to allow enough time for your care. If you miss an appointment, you may have to wait for another opening. If you miss two appointments, you may be only able to make same-day appointments. By calling us when you are unable to make your scheduled appointment, we are able to see other patients waiting for an appointment. These rules are firm so that we can serve everyone in need of care.

Stomach ProblemsYes No DK

Stomach Pain .............................

Heartburn....................................

History of Ulcers .........................

Colitis ..........................................

Comments ________________________

Yes No DK

Diabetes - Type I .......................

Diabetes - Type II ......................

Thyroid Problems .......................

Other Gland Problems ................

Comments ________________________

Breathing/Lung ProblemsYes No DK

Hay Fever ..................................

Shortness of Breath ....................

Persistent Cough ........................

Positive Test/Treatment for Tuberculosis ..........................

Seasonal Allergies ......................

Asthma .......................................

Emphysema................................

Coughing up Blood .....................

Comments ________________________

Heart and Circulatory ProblemsYes No DK

Heart Attack ................................ If yes, when _______________________

High Blood Pressure...................

Chest Pain (Angina) ...................

Heart Murmurs ............................

Artifical Valves ............................

Other Heart Problems.................

Comments ________________________

Neurologic ProblemsYes No DK

Epilepsy/Seizures ......................

Chronic Headaches ....................

History of Head Injury .................

Numbness of Arms, Legs, Hands or Feet ...................

History of Stroke ......................... If yes, when _______________________

Fainting Spells ............................

Comments ________________________

Muscle and Bone ProblemsYes No DK

Joint/Back Pain ...........................

History of Broken Bones .............

Joint Swelling..............................

Arthritis .......................................

Comments _______________________

LiverYes No DK

Hepatitis A, B, or C .....................

Alcoholic Liver Disease ..............

Other Liver Disease ....................

Jaundice .....................................

Comments ________________________

Mental Health ProblemsYes No DK

Depression .................................

Anxiety ........................................

History of PsychiatricMedications ................................

Comments ________________________

Skin ProblemsYes No DK

Rashes .......................................

Mole Changes ............................

Comments ________________________

Do you have any other disease, condition or problem not listed?..

If Yes, please explain ________________ ________________________________

Blood ProblemsYes No DK

Bleeding Problems .....................

Anemia .......................................

Hemophilia..................................

Are you taking blood thinners? ... If yes, recent INR level ______________

Comments ________________________

OtherYes No DK

Domestic Abuse..........................

Immune System Disorders .........

Venereal Disease .......................

AIDS/HIV ....................................

Kidney or BladderProblems ....................................

Frequent Urinary Tract Infections ...........................

Comments ________________________

Dental Patient Medical History ForM

________________________________________________________________________________Signature of Patient or Guardian Date Signature of Hygienist Signature of Dentist Date Not Applicable Supervising TreatingBurmese

လနာအမည- ________________________________________________________________ ေမြးေန႔- _______________________________ ေန႔စြ- _______________________

သြားကနးမာေရး၊ လနာ၏ ေဆးကသမႈ မတတမး

ေဆးကသမႈဆငရာ အခကအလက- “ဟတသည” “မဟတပါ” “မသပါ” ဟ သငေလာေသာ အေျဖက ေျဖဆပါ-

ႏလးႏင ေသြးလညပတမႈဆငရာ ျပနာမား

ဟတသည မဟတပါ မသပါ

ႏလးအေမာေဖာကျခငး .......................................... ရခပါက မညသညအခနကနညး ____________________________

ေသြးေပါငခနတကျခငး ..........................................

ရငဘတေအာငျခငး (Angina) ..................................

ႏလးခနသ မမမနျခငး ...........................................

ႏလးအဆ႔ရင အတ ...............................................

အျခားႏလးျပနာမား ..........................................

မတခက _____________________________________________

ဟတသည မဟတပါ မသပါ

ဆးခ - အမ းအစား I ............................................

ဆးခ - အမ းအစား II ...........................................

သငး႐ြကဂလငး ျပနာမား ..................................

အျခားဂလငး ျပနာမား .......................................

မတခက _____________________________________________

အသက႐ျခငး/အဆတ ျပနာမား

ဟတသည မဟတပါ မသပါ

ဓာတမတညဖားနာျခငး (Hay Fever) ........................

အေမာေဖာကျခငး ................................................

နာတာရညေခာငးဆျခငး ........................................

အဆတတဘ ပးေတြ႔ျခငး/ကသမႈခယျခငး....................

ရာသအလက ဓာတမတညမႈ ....................................

ရငၾကပ ..............................................................

အဆတေလအတငယမား ေယာငျခငး (Emphysema) ....

ေခာငးဆးေသြးပါ ..................................................

မတခက _____________________________________________

အေရျပားျပနာမား

ဟတသည မဟတပါ မသပါ

အပန႔မား ............................................................

မ႔ေျပာငးလျခငး.....................................................

မတခက _____________________________________________

ဝမးဗကဆငရာ ျပနာမား

ဟတသည မဟတပါ မသပါ

ဗကနာျခငး ..........................................................

ရငပျခငး .............................................................

အနာရခဖးျခငး ....................................................

အမႀကးေယာငျခငး ................................................

မတခက _____________________________________________

စတကနးမာေရးျပနာမား

ဟတသည မဟတပါ မသပါ

စတဓာတကျခငး ..................................................

စတလႈပရားလြယျခငး.............................................

စတေရာဂါ ကသမႈ ခယဖးျခငး ..................................

မတခက _____________________________________________

အ႐းႏငၾကြကသား ျပနာမား

ဟတသည မဟတပါ မသပါ

အ႐းအဆစ/ ေကာနာျခငး ......................................

အ႐းကးဖးျခငး .....................................................

အ႐းဆကေယာငျခငး (Joint swelling) ......................

အဆစအျမစေယာငျခငး ........................................

မတခက _____________________________________________

အသညး

ဟတသည မဟတပါ မသပါ

အသညးေရာင ေအ၊ ဘ သ႔မဟတ စ ..........................

အရကေၾကာငျဖစေသာ အသညးေရာဂါ .......................

အျခား အသညးေရာဂါ ............................................

အသားဝါေရာဂါ ....................................................

မတခက _____________________________________________

အာ႐ေၾကာဆငရာျပနာမား

ဟတသည မဟတပါ မသပါ

ဝက႐းျပနျခငး/တကျခငး ........................................

နာတာရညေခါငးကကျခငး ......................................

ဥးေခါငးဒဏရာ ရဖးျခငး ........................................

ေျခလကထကငျခငး ..............................................

ေလျဖတဖးျခငး ...................................................

ရခပါက မညသညအခနကနညး ____________________________

မးေမလတတျခငး ................................................

မတခက _____________________________________________

ေသြးျပနာမား

ဟတသည မဟတပါ မသပါ

ေသြးထြကျခငး ....................................................

ေသြးအားနညးျခငး ................................................

ေသြးနဥအားနညးျခငး ............................................

သင ေသြးကေဆး ေသာကေနပါသလား?

ေသာကပါက ၿပးခေသာအႀကမ၏ INR ပမာဏ __________________

မတခက _____________________________________________

အျခား

ဟတသည မဟတပါ မသပါ

အမတြငးအႏငကငအၾကမးဖကျခငး .........................

ကယခအား ကဆငးျခငး ........................................

လငမတစဆင ကးစကတတေသာေရာဂါ .....................

အတခအငဗြ/ေအအငဒအကစ

ေကာကကပ သ႔မဟတ ဆးအတ ျပနာမား ............

မၾကာခဏ ဆးလမးေၾကာငး ပးဝငျခငး .......................

မတခက

သငတြင အထကတြင ေဖာျပထားသညတ႔တြင မပါဝငသည အျခား ေရာဂါ၊ အေျခအေန သ႔မဟတ ျပနာ ရပါသလား?

ရပါက ရငးျပပါ ________________________________________ ___________________________________________________

ကၽြႏပေျဖဆထားသည အားလးတ႔သည ကၽြႏပသရရသမ အတငးအတာအထ မနကနမႈ ရပါသည။ ကၽြႏပတြင ကနးမာေရး သ႔မဟတ ေဆးကသမႈ အေျခအေနမား ေျပာငးလမႈတစခခ ရလာပါက ကၽြႏပ၏ ကနးမာေရးေစာငေရာကသက ခကခငး အေၾကာငးၾကားပါမည။ ကၽြႏပအား သ႔မဟတ အမညပါ လနာ (ကၽြႏပသည ထသ၏ မဘ၊ တရားဝင အပထနးသ သ႔မဟတ ေမြးစားမဘ) အား ကသမႈေပးရန သေဘာတပါသည။ ကၽြႏပတ႔မ သငအတြက အခနသးသန႔ ေပးထားပါသည။ သငသည ေနာကကမညဆပါက သ႔မဟတ ခနးဆမႈက ေျပာငးလရန လအပပါက အျမနဆး ဖနးေခၚပါ။ ေနာကကလာျခငးျဖင သငက ေစာငေရာကမႈေပးသက သငအတြက အခနအလအေလာကရေစရန သငႏငအခနးအခကက ျပနလညစစဥရန လအပပါသည။ သငသည ခနးဆမႈက လြေခာပါက ေနာကထပတစႀကမအထ ေစာငရနလပါမည။ သငသည ခနးဆမႈႏစႀကမက လြေခာခပါက တစရကထတြငသာ ခနးဆမႈမား ျပနလညျပလပႏငမည ျဖစပါသည။ သငခနးဆမႈက မလာေရာကႏငေၾကာငး ကၽြႏပတ႔က ဖနးေခၚအေၾကာငးၾကားျခငးျဖင ခနးဆမႈ ျပလပလေသာ အျခားလနာမားအတြက အခနေပးႏငမညျဖစပါသည။ ယခ စညးမဥးမားသည အခငအမာျဖစၿပး သ႔မသာ ေစာငေရာကမႈလအပသ လတငးအတြက ကၽြႏပတ႔ ဝနေဆာငမႈေပးႏငမည ျဖစပါသည။ လနာသ႔မဟတ အပထနးသ၏လကမတ ေန႔စြ သြားကနးမာေရးပညာရငလကမတ သြားဆရာဝနလကမတ ေန႔စြ

Rev Jan2013 CRD မရပါ ႀကးၾကပ ကသ

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