Temple University School of Dentistry - Odontolog Yearbook (Philadelphia, PA)

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Temple University School of Dentistry Health Questionnaire Appleby Dr David Last First Ml Fixed Removable Address Kornberg City State Zip Code Social Security Number Home Phone Work Phone Answer all questions by circling YES” or NO’ and fill in all blank spaces when indicated. 1. No Yes ... Has there been any change in your general health within the past year? If yes. what was the change? Anxiety caused by seniors not being able to fill out authorization forms correctly 2. No Yes ... Have you ever been hospitalized or under the care of a physician? If yes. what was the problem? Fatigue from having to do everyone's work for them 3. No Yes ... Are you now under the care of a physician? If yes. for what? Dr Tarnoff helps me cope with these conditions DO YOU HAVE, OR HAVE YOU HAD ANY OF THE FOLLOWING: 4. No Yes ... Rheumatic fever or rheumatic heart disease7 5. No Yes ... Heart murmur? 6. No Yes ... Heart trouble, heart attack, stroke, pacemaker, or prosthetic (artificial) heart valve? 7. No Yes ... Shortness of breath or chest pain after mild exercise? 8. No Yes ... Shortness of breath when you lie down7 9. No Yes ... Do you use more than 2 pillows to sleep? 10. No Yes ... High Blood Pressure 11. No Yes ... Do your ankles swell? 12. No Yes ... Asthma, emphysema or difficulty in breathing? 13. No Yes ... Seizures or convulsions7 14. No Yes ... Diabetes? 15. No Yes ... A loss or gain of 10 pounds or more in the past year7 16. No Yes ... Frequent urination (pass water more than 6 times a day)? 17. No Yes .. Excessive thirst? 18. No Yes ... Hepatitis, jaundice or liver disease7 19. No Yes ... AIDS or HIV+? 20. No Yes.. Arthritis? 21. No Yes ... Cancer Chemotherapy? 22 No Yes ... Stomach ulcers? 23. No Yes ... Kidney trouble or renal dialysis? 24. No Yes ... Tuberculosis? 25. No Yes ... A persistent cough or coughing up blood7 26. No Yes ... Venereal disease, gonorrhea, syphilis7 27. No Yes ... Psychiatric therapy? 28. No Yes ... Thyroid disease? 29. No Yes ... Have you had any artificial bones or joints (prosthesis) implanted? 30. No Yes ... Do you have any blood disorder such as anemia or sickle cell disease? 31. No Yes ... Have you had surgery or radiation (x-ray) treatment for a tumor, growth, cancer or other condition of your head, neck or mouth? 32. No Yes ... Do you bleed excessively after you are cut? 33. No Yes ... Have you ever required a blood transfusion? 34. No Yes ... Have you ever been denied permission to give blood7 35 No Yes ... Do you have any hearing or visual problems, or other disabilities which we should consider in planning your dental treatment (e g. glaucoma)? 36. No Yes ... Do you have a family history of heart disease, diabetes or immunological diseases such as lupus7 (---------------------------------------------------------------- Medical Doctor's Name and Address: Dr Louis Tarnoff Date of last visit: Condition being treated: My major dental problem or reason for seeking treatment is. Date of Birth; Today's Date: (1) 5

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Dean Martin Tansy School of Dentistry TEMPLE UNIVERSITY Office of the D«an phone 2IS-707-2799 3227 N«tti Brojd Street 1601001 Ui 2IS-707-3192 Pwinsyfvaiw 19140 Mav 17.2007 a To The Class of 2007: I congratulate you on being the very first class to graduate from Temple University’s newly-named Komberg School of Dentistry Your Temple University diploma will reflect not only that you graduated from one of the most respected dental schools in the nation, but also that it is now Temple University. Maurice H. Komberg School of Dentistry. We arc honored to have been selected to receive this gift in honor of Maurice H. Komberg. which will provide scholarship relief to dental students for years to come and I am glad to extend that honor to the very excellent Class of 2007. You have exceeded our expectations, which were high. You have made your mark as an extremely professional and capable group of young men and women. I am confident you will continue to excel as you go on to practice your profession. I thank you for being such an excellent class, and wish you the best of luck in your future endeavors. Sincerely. 4

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Faculty Dedication Dr. Andrea Haber-Cohen Department of Oral and Maxillofacial Surgery The Class of 2007 proudly dedicates the 2007 Odontolog to Dr. Andrea Haber-Cohen. Although she was a little intimidating at first, today we realize that her tough love was just her style to get the best out of each and every one of us. We are truly blessed to have been trained by such a knowledgable and inspirational surgeon. Thank you Dr. Cohen!