SYDNEY ORAL MEDICINE YOUR DETAILS (Please print clearly)
Title. . . . . . . . . .Surname………………………Given Names…………………….…….
Date of birth………….……………………………. Gender: □ Male □ Female
Address………………………………………………………………………………….…
Suburb……………………………….State……………Postcode….….…
Telephone:.(H)………………………………….(M)………………………………………
(B)………………………………………Occupation.
Email……………………………………………………………………………………….
NEXT OF KIN/PERSON TO CONTACT IN EMERGENCY
Name:………………………………….Relationship to patient………………………….
PRIVATE HEALTH INSURANCE & MEDICARE
Do you have Private Health Insurance with Dental cover? □ Yes □ No
Medicare card no…………………………….Ref.no………………Expiry date…………
Person responsible for accounts (if not self)……………………………………………….
Are you happy for us to confirm your appointments via SMS on your mobile?
If not, would you prefer: □ Email □ Phone Referring Doctor:
. YOUR MEDICAL HISTORY
Please tick “Yes” if you have now, or have had in the past, any of the following:
Heart condition or murmur □ Yes □ No Muscle, bone, joint problems □ Yes □ No
Rheumatic fever □ Yes □ No Immune system problems □ Yes □ No
High blood pressure □ Yes □ No Gastrointestinal problems □ Yes □ No
Bleeding problems □ Yes □ No Urogenital problems □ Yes □ No
Respiratory problems □ Yes □ No Liver problems □ Yes □ No
Nervous system problems □ Yes □ No Cancer □ Yes □ No
Thyroid problems □ Yes □ No Pregnancy □ Yes □ No
Diabetes □ Yes □ No Smoking □ Yes □ No
Infectious diseases □ Yes □ No Alcohol □ Yes □ No
Osteoporosis □ Yes □ No Betel nut use □ Yes □ No
Medications…………………………………………………………………………………
………………………………………………………………………………………………
Have you ever been prescribed any of the following medications? Zometa™,
Pamidronate™, Bonefos™, Actonel™, Fosamax™ .
Hospital admissions……………………………………………………………………….
………………………………………………………………………………………………
Allergies…………………………………………………………………………………….
.…………………………………………………………………………………………….
Other…………………………………………………………………………………….…
FAMILY DOCTOR’S DETAILS
Doctor’s Name…………………………………………………………………………….
Address…………………………………………………………………………………….
Telephone………………………………………………………………………………….
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Estradiol Increases Beta-Catenin Binding to Nuclear TCF/LEF: A Novel Hormone-Dependent Mechanism for Wnt Signaling in the Rat Uteru s Meryl Twarog and Virginia Rider Department of Biology, Pittsburg State University, Pittsburg, Kansas 66762 An Abstract of a Presentation to: K-INBRE Research Symposium, KSU, Manhattan, KS (January 2006) Previous studies in our laboratory showed that progestero