CAMPER HEALTHCARE RECOMMENDATIONS BY LICENSED MEDICAL PERSONNEL FORM 2 To Parents(s)/Guardian(s): Complete this section and give this form (FORM 2) and a copy of your completed CAMPER HEALTH HISTORY FORM (FORM 1) to your child’s health-care provider for review. Camp Glen Brook Dates will attend camp: _____/_____/_____ to _____/_____/_____ 35 Glen Brook Rd. Month Day Year M
Southerndentalgroup.netWe are pleased to welcome you to our practice. Please take a few minutes to fill out this form as completely as you can. We are
looking forward to working with you on maintaining your health.
Patient_____________________________________________________Sex: M F DOB:___________________ Marital: S M W D Address____________________________________ _______City _______________ State ____________ Zip __________________ Home Phone _______________________Cell _____________________SS # ___________________Pharmacy _________________ Email ______________________________________Occupation/Employer _____________________Work Phone_______________ Who should be notified in case of an emergency?____________________________________ # ______________________________ How would you prefer for us to contact you? Home phone Work phone Cell phone Whom may we thank for referring you to our office? _________________________________________________________________ Primary Dental Insurance
Insured’s Name___________________________Relationship ________________ DOB ______________SS#___________________ Address_____________________________________________________________________________________________________ Employer _______________________________ _Insurance Co.________________________________________________________ Secondary Dental Insurance
Insured’s Name___________________________Relationship ________________ DOB _________ _SS#______________________ Address_____________________________________________________________________________________________________ Employer _______________________________ Insurance Co._________________________________________________________ Medical History
Former Dentist___________________________ Address_________________________________ Phone # _____________________
Physician’s Name___________________________________ Phone # ____________________ Last Visit ______________________
Are you currently under a physician’s care? ________ _If yes, describe __________________________________________________
Have you ever been hospitalized, had major operations or serious illness? ________________________________________________
Have you ever had a blood transfusion? _________ If yes, give approximate dates _________________________________________
Women: Do you suspect that you are pregnant? ______Are you nursing? _______ Do you take birth control pills?________________
Do you use any tobacco products? _______What kind? ________________ How long? ________How much per day?_____________
Please check if you currently have, or have ever had any of the following:
__ Mitral Valve Prolapse
Are you taking or have you ever taken bone replacement medications? (Ex. Boniva, Fosamax, Actonel, Zometa, etc.) _____________
List any medications you are currently taking_______________________________________________________________________
List any drug allergies__________________________________________________________________________________________
- I authorize the release of my dental records and medical information to Dr. Michael E. Pope.
- I consent to treatment considered necessary by the dentist or qualified designate.
Signature______________________________________________________________ Date ________________________________
CHET HIGHER EDUCATION CROSS-NATIONAL PERFORMANCE INDICATORS: EDUARDO MONDLANE UNIvERSIT yThis section deals with the Eduardo Mondlane’s student enrolments over the period 2000/01-2007/08. Data for the years 2008/09 to 2009/10 were not available. Graph 1 below shows how Eduardo Mondlane University’s head count student enrolments changed over the period 2000/1-2007/8. It should be noted that