Report from the Kennel Club/ British Small Animal Veterinary Association Scientific Committee
|
|
|
- Gilbert Farmer
- 7 years ago
- Views:
Transcription
1 Report from the Kennel Club/ British Small Animal Veterinary Association Scientific Committee Summary results of the Purebred Dog Health Survey for Border Terriers Warning: The results of this survey and particularly the breed-specific analyses should be interpreted with caution. The overall response rate was only % with breed-specific response rates from.5% to 6.7%.
2 Border Terriers A total of 58 forms were sent out and 15 were returned, representing 5 live dogs. This breed had a 8.8 % response rate (15/58) and it represented 1.11% of all returns (15/13,71). Mortality data A total of 177 deaths were reported and this represents 1.11 % of all deaths reported in the survey (177/15,881). The median age at death for Border Terriers was 1 years (min = months, max = years and 1 month) and this was higher than the overall median of 11 years and 3 months (Figure 1). Table 1 shows the causes of death for Border Terriers. Age at death is presented for the most common causes of death (Figure ). Table 1. Causes of death by organ system/category for Border Terriers. Cause of death No. of deaths % of deaths Most common specific causes in descending order 1 Old age Old age & age combinations Cancer Type unspecified, lymphoma, carcinoma 3 Trauma Road traffic accident, attacked by dog, unspecified Urologic Chronic kidney failure, unspecified 5 Combinations Kidney and liver failure, seizures 6 Cerebrovascular 8.5 Stroke or cerebral vascular accident 7 Hepatic 6 3. Chronic liver failure 8 Behaviour 5.8 Aggression 9 Cardiac 5.8 Failure, murmur, attack 1 Gastrointestinal 5.8 IBD, colitis, foreign body, unspecified 11 Neurologic 5.8 Seizures, intervertebral disc disease 1 Endocrine Diabetes mellitus, Cushings 13 Respiratory Pneumonia, emphysema, unspecified 1 Musculoskeletal 1.1 Arthritis, muscle weakness 15 Other 1.1 Uncodeable 16 Perioperative Unknown Collapse Immune mediated 1.6 Immune disorder unspecified Poisoning Portosystemic shunt 1.6 Senility 1.6 Total Cancer: lymphosarcoma=lymphoma Gastrointestinal: IBD=inflammatory bowel disease Endocrine: Cushings disease=hyperadrenocorticism
3 breed: Border Terrier Frequency Age_at_death 5 Figure 1. Histogram showing the frequency (as number of dogs) of age at death (in years) for the 177 Border Terrier deaths with age at death reported. Figure. Box and whisker plot of age at death in years for the most common causes of death in Border Terriers (N=177). The dashed line ( ) is the overall median age at death for all dogs in the survey and the dotted line (----) is the overall median age of death for Border Terriers. The solid line within each grey box represents the median age at death from the condition. 3
4 Morbidity data The median current age of the 5 live dogs with a reported age was years and 7 months (min=1 month, max=17 years and 3 months, Figure 3). Health information was reported for 5 live dogs of which 376 (75%) were healthy and 18 (5%) had at least one reported health condition, resulting in a total of 177 reported conditions with a median of 1 condition/dog (min=1, max=). The median current age of all healthy dogs with a reported age (N=376) was 3 years and 9 months (min=1 month, max=15 years and 5 months). The distribution of gender and neuter status is shown in Table. The median current age of all dogs with one or more disease conditions and a reported age (N=18) was 8 years (min=1 year and months, max=17 years and 3 months). The median age at diagnosis for all disease occurrences with a reported age at diagnosis (N=16) was years and 1 month (min= months, max= 1 years and 6 months, Figure ). Table 3 shows the disease conditions for Border Terriers. Age at diagnosis is presented for the most common disease conditions (Figure 5). Table. Distribution of gender and neuter status for 99 Border Terriers with reported gender and neuter status. Neuter status Gender Intact Neutered Totals Female (66%) Male (3%) Totals 399 (8%) 1 (%) 99 (1%) Significantly more females were neutered (P=.1). 18 breed: Border Terrier Frequency Current_age Figure 3. Histogram showing frequency of current age in years for the 5 live Border Terriers with age reported.
5 breed: Border Terrier 5 Frequency Age_at_diagnosis Figure. Histogram showing frequency of age at diagnosis for the 18 Border Terriers with one or more disease conditions, using the youngest age at which a disease condition was first reported for those dogs with more than one disease condition or episode. Figure 5. Box and whisker plot of age at diagnosis in years for the most common disease conditions in descending order for Border Terriers (N=117 conditions with age reported). The dashed line ( ) is the overall median age at diagnosis for all dogs in the survey and the dotted line (----) is the overall median age at diagnosis for Border Terriers. The solid line within each grey box represents the median age at diagnosis from the condition. 5
6 Table 3. Disease conditions by organ system/category for Border Terriers. All conditions Prevalence Disease condition N % % Most common specific conditions in descending order 1 Reproductive Dystochia, pyometra, false pregnancy, infertility, irregular heats eclampsia, prostatic disease, cryptorchid Dermatologic Dermatitis, cheyletiella, demodex, fading nose pigment, pyoderma, ringworm, seborrhoea 3 Musculoskeletal Arthritis, patellar luxation, prognathism, fracture, avascular necrosis FH, CHD, CLR, tendon injury, tail abnormality Ocular Cataracts, conjunctivitis, blindness, blepharitis, epiphora, infection 5 Neurologic Seizures, granulomatous meningoencephalitis (GME), deafness 6 Cardiac Murmur, arrhythmia, VSD, MVD, valve disease unspecified 7 Immune mediated Atopy, food allergy, flea allergy 8 Respiratory Kennel cough, bronchitis, noisy breathing 9 Urologic Bladder infection, incontinence, blood in urine 1 Aural (ears) Otitis externa 11 Gastrointestinal Vomiting, pancreatitis, inappetance, intussusception, gastroenteritis unspecified, colitis 1 Cancer Type unspecified mammary, skin, unspecified, oral carcinoma, nasal adenocarcinoma 13 Dental.3.79 Dental disease, retained puppy teeth 1 Hepatic Unspecified liver disease 15 Trauma Hindlimb, forepaw 16 Anal gland 1.1. Anal sacculitis (anal gland impaction or infection or removal) 17 Behaviour 1.1. Aggression, unspecified 18 Benign neoplasia 1.1. Lipoma 19 Other Uncodeable Cerebrovascular 1.6. Stroke or cerebral vascular accident 1 Endocrine 1.6. Diabetes mellitus Total Reproductive: dystochia= uterine inertia (failure to push) slightly>physical blockage (stuck puppy) Dermatologic: dermatitis=undiagnosed skin irritation or scratching or itchy skin or pruritis Musculoskeletal: FH=femoral head, CHD=canine hip dysplasia, CLR=cruciate ligament ruptures Cardiac: VSD=ventricular septal defect, MVD=mitral valve disease Gastrointestinal: inappetance=loss of appetite or anorexia
Report from the Kennel Club/ British Small Animal Veterinary Association Scientific Committee
Report from the Kennel Club/ British Small Animal Veterinary Association Scientific Committee Summary results of the Purebred Dog Health Survey for the Samoyed breed Warning: The results of this survey
Report from the Kennel Club/ British Small Animal Veterinary Association Scientific Committee
Report from the Kennel Club/ British Small Animal Veterinary Association Scientific Committee Summary results of the Purebred Dog Health Survey for British Bulldogs Warning: The results of this survey
Report from the Kennel Club/ British Small Animal Veterinary Association Scientific Committee
Report from the Kennel Club/ British Small Animal Veterinary Association Scientific Committee Summary results of the Purebred Dog Health Survey for Old English Sheepdogs Warning: The results of this survey
Report from the Kennel Club/ British Small Animal Veterinary Association Scientific Committee
Report from the Kennel Club/ British Small Animal Veterinary Association Scientific Committee Summary results of the Purebred Dog Health Survey for the Alaskan Malamute breed Warning: The results of this
Report from the Kennel Club/ British Small Animal Veterinary Association Scientific Committee
Report from the Kennel Club/ British Small Animal Veterinary Association Scientific Committee Summary results of the Purebred Dog Health Survey for Flatcoated Retrievers Warning: The results of this survey
Report from the Kennel Club/ British Small Animal Veterinary Association Scientific Committee
Report from the Kennel Club/ British Small Animal Veterinary Association Scientific Committee Summary results of the Purebred Dog Health Survey for Labrador Retrievers Warning: The results of this survey
Report from the Kennel Club/ British Small Animal Veterinary Association Scientific Committee
Report from the Kennel Club/ British Small Animal Veterinary Association Scientific Committee Summary results of the Purebred Dog Health Survey for French Bulldogs Warning: The results of this survey and
Report from the Kennel Club/ British Small Animal Veterinary Association Scientific Committee
Report from the Kennel Club/ British Small Animal Veterinary Association Scientific Committee Summary results of the Purebred Dog Health Survey for Cavalier King Charles Spaniels Warning: The results of
Report from the Kennel Club/ British Small Animal Veterinary Association Scientific Committee
Report from the Kennel Club/ British Small Animal Veterinary Association Scientific Committee Summary results of the Purebred Dog Health Survey for Golden Retrievers Warning: The results of this survey
Report from the Kennel Club/ British Small Animal Veterinary Association Scientific Committee
Report from the Kennel Club/ British Small Animal Veterinary Association Scientific Committee Summary results of the Purebred Dog Health Survey for Irish Wolfhounds Warning: The results of this survey
Pekingese Breed Death Report
Report from the Kennel Club/ British Small Animal Veterinary Association Scientific Committee Summary results of the Purebred Dog Health Survey for the Pekingese breed Warning: The results of this survey
Irish Wolfhound Pedigree Breed Health Survey
Irish Wolfhound Pedigree Breed Health Survey Forms were received representing 74 living dogs & 32 deceased dogs. Mortality results A total of 32 deaths were reported, representing 0.57% of all deaths reported
Chesapeake Health Survey Results 2014
No. of dogs Chesapeake Bay Retriever Club Chesapeake Health Survey Results This health survey is the first of a two-part survey of Chesapeake Bay Retrievers in the UK, carried out by the Chesapeake Bay
The Health of British Flatcoated Retrievers
1 Analysis of 2011 Survey of The Health of British Flatcoated Retrievers Many thanks to the owners who took the time to complete the questionnaire and who also provided case histories or laboratory reports
PATIENT HEALTH QUESTIONNAIRE Radiation Oncology (Patient Label)
REVIEWED DATE / INITIALS SAFETY: Are you at risk for falls? Do you have a Pacemaker? Females; Is there a possibility you may be pregnant? ALLERGIES: Do you have any allergies to medications? If, please
NEW PATIENT CONSULTATION FORM. Social Security Number - - Date of Birth Age. Home Address. Home phone Cell phone. Work phone Email address
NEW PATIENT CONSULTATION FORM Welcome to our office. Please fill out the first four pages. Date Name Social Security Number - - Date of Birth Age Home Address Home phone Cell phone Work phone Email address
Emory Eye Center New Patient Questionnaire
Patient Name: Date: Current Address: Current Phone: Date of Birth: Primary Care Physician: Referring Physician: (First & Last Name) (First & Last Name) Pharmacy Name: Phone #: ( ) Please answer all questions
Medical Surgical Nursing (Elsevier)
1 of 6 I. The Musculoskeletal System Medical Surgical Nursing (Elsevier) 1. Med/Surg: Musculoskeletal System: The Comprehensive Health History 2. Med/Surg: Musculoskeletal System: A Nursing Approach to
Medical Specialties Guide
Medical Specialties Guide Allergy And Immunology Specialists in this field treat disorders related to how the body reacts to foreign substances. They treat such things as seasonal allergies, eczema, asthma,
Patient Medical History
Cardiovascular Abnormal Electrocardiogram Aortic Stenosis Atrial fibrillation Cardiac arrest Chest pain Congestive heart failure Heart valve replacement Hypertension Murmur Heart attack Palpitations Peripheral
SOUTH TAMPA MULTIPLE SCLEROSIS CENTER
SOUTH TAMPA MULTIPLE SCLEROSIS CENTER PATIENT/CARE GIVER QUESTIONNAIRE DEMOGRAPHIC INFORMATION Patient's Name: City: State: Zip Code: Phone: Marital Status: Spouse/Care Giver Name: Phone (H) (W) Occupation:
Kidney or renal disease
Kidney or renal disease VETERINARY GUIDE 6 The kidneys are responsible for filtering waste products out of the blood to form urine. Disease of the kidneys is one of the most common problems affecting middle-aged
NEURO-OPHTHALMIC QUESTIONNAIRE NAME: AGE: DATE OF EXAM: CHART #: (Office Use Only)
PAGE 1 NEURO-OPHTHALMIC QUESTIONNAIRE NAME: AGE: DATE OF EXAM: CHART #: (Office Use Only) 1. What is the main problem that you are having? (If additional space is required, please use the back of this
PLEASE COMPLETE PRIOR TO VISIT***Place your name at the bottom of each sheet
PLEASE COMPLETE PRIOR TO VISIT***Place your name at the bottom of each sheet GASTROINTESTINAL ASSOCIATES, INC. PATIENT REGISTRATION Welcome to our practice. Please complete all sections of this registration
WORKERS COMPENSATION INFORMATION
WORKERS COMPENSATION INFORMATION PATIENT REGISTRATION INFORMATION 15215 Shady Grove Rd. # 100 Patient Name: Last First MI Address: Street City State Zip Home Phone: Cell Phone: Work Phone: Primary Doctor:
POINCIANA INTERNAL MEDICINE PA. Patient Name: Social Security Number: Date of Birth: / / Sex: M/F (Circle One) Married/Single/Divorced/Widow Address:
Patient Name: Social Security Number: Date of Birth: / / Sex: M/F (Circle One) Married/Single/Divorced/Widow Address: (Street) (City/State/Zip) Home Phone: ( ) E Mail Address: Would you be interested in
Dallas Neurosurgical and Spine Associates, P.A Patient Health History
Dallas Neurosurgical and Spine Associates, P.A Patient Health History DOB: Date: Reason for your visit (Chief complaint): Past Medical History Please check corresponding box if you have ever had any of
PLEASE PRINT LEGIBLY
Patient Information PLEASE PRINT LEGIBLY Patients Name: Date of Birth: Sex: Patients Address: City: State: Zip: Home Phone: Cell: Work: Email: SSN: Employer: Occupation: Marital Status: Employed: Full
PELED PLASTIC SURGERY HEADACHE HISTORY FORM
HEADACHE HISTORY FORM IF THIS IS YOUR FIRST VISIT, PLEASE TAKE THE TIME TO FILL THIS FORM OUT COMPLETELY. Patient Name: Age: Date of Birth: Weight: Height: Address: City: State: Zip: Home Phone: Cell Phone:
Pulmonary Associates of Richmond
Pulmonary Associates of Richmond Name: Address One: City: Home Phone#: Work Phone#: Cell Phone#: State: Zip: Sex: Social Security Number: Referring Doctor: of Birth: Employer: Primary Care Doctor: Employment
SOUTH TAMPA MULTIPLE SCLEROSIS CENTER PATIENT/ CARE GIVER QUESTIONNAIRE
SOUTH TAMPA MULTIPLE SCLEROSIS CENTER PATIENT/ CARE GIVER QUESTIONNAIRE DEMOGRAPHIC INFORMATION Patient Name: Date: Address: City: State: Zip Code Best Phone Number: Marital Status Phone (H): (W) (Cell):
Generali Worldwide Group Health Insurance Enrolment and Health Insurance Applicant Form
Generali Worldwide Group Health Insurance Enrolment and Health Insurance Applicant Form Please complete all sections in BLOCK CAPITALS or tick the boxes, where appropriate. A completed Health Insurance
St. Luke s MS Center New Patient Questionnaire. Name: Date: Birth date: Right or Left handed? Who is your Primary Doctor?
St. Luke s MS Center New Patient Questionnaire Name: Date: Birth date: Right or Left handed? Who is your Primary Doctor? Who referred you to the MS Center? List any other doctors you see: Reason you have
Notice of Privacy Practices
Notice of Privacy Practices This notice describes how medical information about you may be used and disclosed, and how you may obtain access to this information. Please review it carefully. OMAC respects
Roswell Ear, Nose, Throat, & Allergy 342 W. Sherrill Lane Suite A, Roswell, New Mexico 88201 (575)-622-2911 Fax: (575)-622-2598
Roswell Ear, Nose, Throat, & Allergy 342 W. Sherrill Lane Suite A, Roswell, New Mexico 88201 (575)-622-2911 Fax: (575)-622-2598 Patient Registration Form: (Please Print all Pertinent Information) Last
Thank you for making an appointment with our office. We look forward to serving your visual needs.
Dear New Patient, Thank you for making an appointment with our office. We look forward to serving your visual needs. Enclosed you will find our New Patient Questionnaires. Please complete these and fax
NEW PATIENT HISTORY QUESTIONNAIRE. Physician Initials Date PATIENT INFORMATION
NEW PATIENT HISTORY QUESTIONNAIRE Physician Initials Date PATIENT INFORMATION JHH# DOB# AGE HOME PH CELL PH DAY PH EMAIL Who is your REFERRING PHYSICIAN? (The doctor who referred you to Johns Hopkins Neurology.)
CIGNA GLOBAL HEALTH OPTIONS APPLICATION FORM HELLO
CIGNA GLOBAL HEALTH OPTIONS APPLICATION FORM HELLO We re glad you would like to join us. Please complete this application form and return it to us, either by electronic mail, fax or post. See our contact
MEDICAL EXAM QUESTIONNAIRE APPLICATION SUPPLEMENT
Hartford Life Insurance Company Hartford Life and Annuity Insurance Company MEDICAL EXAM QUESTIONNAIRE APPLICATION SUPPLEMENT INSTRUCTIONS FOR THE MEDICAL EXAMINER DETACH AND DISCARD BEFORE MAILING THE
JAMES PETROS, M.D., INC. PHONE: (408) 528-8833 FAX: (408) 528-8557
FIGHTING PAIN. TOUCHING LIVES. JAMES PETROS, M.D., INC. PHONE: (408) 528-8833 FAX: (408) 528-8557 Personal Information Emergency Contact Today s Date: Name: Patient: Realtionship: Birth Date: Age: Sex:
The insurance company checked above (Company) is responsible for the obligation and payment of benefits under any policy that it may issue.
American International Life Assurance Company of New York* Home Office: 80 Pine Street, New York, NY 10005 The United States Life Insurance Company in the City of New York* Home Office: 830 Third Avenue,
Full name DOB Age Address Email Phone numbers (H) (W) (C) Emergency contact Phone
DEMOGRAPHIC INFORMATION Full name DOB Age Address Email Phone numbers (H) (W) (C) Emergency contact Phone CARE INFORMATION Primary care physician: Address Phone Fax Referring physician: Specialty Address
PATIENT INFORMATION INSURANCE INFORMATION
(mm/dd/yyyy): Have you been to Physicians Urgent Care before? Yes No Arrival Time: If yes, when? Is this a follow-up to a previous visit: Yes No PATIENT INFORMATION Patient s First Name: Middle Name: Last
Healthcare services requiring prior authorisation
Annex 2 Healthcare requiring prior authorisation This list does not include organ transplants and does also not apply to long-term care and the primary purpose of which is to support people in need of
MEDICAL HISTORY AND SCREENING FORM
MEDICAL HISTORY AND SCREENING FORM The purpose of preventive exams is to screen for potential health problems and provide education to promote optimal health. It is best practice for chronic health problems
PurinaCare Pet Health Insurance Accident Only Plan
CENTRAL STATES INDEMNITY CO. OF OMAHA PO Box 34999 1212 N. 96 th Street Omaha, Nebraska 68134-0999 800-833-9145 A Stock Company DIRECT ALL INQUIRIES TO: PurinaCare CSI Insurance Programs P.O. Box 2150
Non-covered ICD-10-CM Codes for All Lab NCDs
Non-covered ICD-10-CM s for All Lab NCDs This section lists codes that are never covered by Medicare for a diagnostic lab testing service. If a code from this section is given as the reason for the test,
Western Center Eye Care 2720 Western Center Blvd Ste 316 Fort Worth, TX 76131
Today s Date Western Center Eye Care WELCOME TO OUR OFFICE Patient s Name (First, Middle, Last): Address: City: State: Zip Code: Email: Main Contact #: Alternate#: Date of Birth: / / Sex: Male Female Primary
New England Pain Management Consultants At New England Baptist Hospital
New England Pain Management Consultants At New England Baptist Hospital Pain Management Center Health Assessment Dear New Pain Management Patient, Welcome to the New England Pain Management Consultants
Insured Party Information (please complete if the insurance is not in your name)
Price M. Kloess, M.D. / Andrew J. Velazquez, M.D. / J. Randall Pitts, M.D. Holly Young, O.D./ Audrey Richards, O.D./ Brittany M. Mitchell, O.D. Patient Registration and Financial Agreement Patient s Dr
Compensation. Service-Connected Disability or Death Benefits
Compensation Service-Connected Disability or Death Benefits The Compensation program provides tax-free monthly benefits to Veterans in recognition of the effects of disabilities caused by diseases, events,
PATIENT HISTORY FORM
PATIENT HISTORY FORM If you are new to the office, have not been seen in over one (1) year, or are returning for a new problem, please complete this form in full. If there have been any changes since your
APPLICATION/ AMENDMENT FORM
BUPA BY YOU APPLICATION/ AMENDMENT FORM Underwritten Thank you for choosing Bupa. Please complete this application form as fully as possible. This form is for new members and existing members wishing to
DATA CAPTURE FORM LIFE INSURANCE
DATA CAPTURE FORM LIFE INSURANCE APPLICANT 1 APPLICANT 2 Title First Names Surname Date of Birth Marital Status Address Telephone Email In which country were you born? In the last 2 years, have you lived
Plano Heart Center, P.A.
Plano Heart Center, P.A. Date: How did you hear about us: Physician Referral Advertisement Friend Other. Please specify: Patient Information Name: Social Security #: Address: City: State: Zip: Home Ph:
Neutering family planning for felines
Neutering family planning for felines ESSENTIAL GUIDE 6 Cats Protection believes that getting your cat neutered before it can breed is an essential part of responsible cat ownership. Cats are very effective
Borland-Groover Clinic PATIENT GENERATED MEDICAL HISTORY Name: DOB: Email: Primary Care Physician: Pharmacy: Pharmacy Phone #:
PATIENT GENERATED MEDICAL HISTORY Name: DOB: Email: Primary Care Physician: Referring: Pharmacy: Pharmacy Phone #: Place Sticker Here Directions: Please circle any of the following you have personally
Life & PHI Application Form
Life & PHI Application Form A. Applicant 1) Mr Mrs Miss Other: 2) Family Name: 3) First Name: 4) Date of Birth: 5) Nationality: 6) Place of Birth: 7) Location of Assignment: 7) Occupation (please give
New Patient Intake Form
New Patient Intake Form Title: (Circle one) Mr. Mrs. Ms. Miss Dr. Other First Name Middle Initial Last Name Address City State Zip Code Leave Messages on: (Circle one) Home Cell Work Don t leave messages
The NeuroCenter Swedish Covenant Medical Group 6225 W. Touhy Ave, Chicago, Il 60646 Tel: 773-775-7540 Fax: 773-763-9792
The NeuroCenter Swedish Covenant Medical Group 6225 W. Touhy Ave, Chicago, Il 60646 Tel: 773-775-7540 Fax: 773-763-9792 1 PAIN MANAGEMENT SERVICES New Patient Questionnaire Date: Primary MD: Referring
Sun Life and Health Insurance Company (U.S.)
Sun Life and Health Insurance Company (U.S.) One Sun Life Executive Park, Wellesley Hills, MA 02481] [800-247-6875 Evidence of Insurability Cover Page Employer Instructions Complete this cover page and
Group Benefits Evidence of Insurability for Comprehensive Optional Critical Illness Insurance
Group Benefits Evidence of Insurability for Comprehensive Optional Critical Illness Insurance INSTRUCTIONS - Please print all answers If required, retain a photocopy for your files. 1a) Plan contract number(s)
Southwestern Foot & Ankle Associates, P.C. 3880 Parkwood Blvd, Suite 602 Frisco, TX 75034 Phone: 972-335-9071 Fax: 972-335-8920 Dr. Thomas H.
Phone: 972-335-9071 Fax: 972-335-8920 Date: Home Phone ( ) Patient Information (Please Print) Email: Name: SS/Patient ID # Last Name First Name Middle Initial Address Cell Phone ( ) City State Zip Sex
PATIENT REGISTRATION FORM
PATIENT REGISTRATION FORM (Please Print) Name: LAST FIRST Ml Street Address: STREET APT CITY STATE ZIP Home Phone #: ( ) ) Cell Phone #: ( ) ) Social Security #: Birth date: Age: Sex: M ; F Marital Status:
CitizenSecure Economy Application and Rates
CitizenSecure Economy Application and Rates Important Instructions for All Applicants 1. Review your answers to each question on this Application for accuracy. Unanswered questions or incomplete information
AUBURN DERMATOLOGY PATIENT DEMOGRAPHIC (Please print legibly)
AUBURN DERMATOLOGY PATIENT DEMOGRAPHIC (Please print legibly) Patient Legal Name: DOB: M/F Home Phone: Work Phone: Cell Phone: Mailing Address: City: State: Zip: Preferred Email: Married: Single: Widowed:
Integrated Medical Services (IMS) New Patient Registration Sheet
Personal Information Today s Date: Patient First Name: Initial: Last Name: DOB: Age: Social Security #: Email: Address: Street Apt # City/State/Zip Home Phone: Work Phone: Cell phone: Gender : M F Language:
PATIENT INFORMATION INSURANCE PHONE NUMBERS ACCIDENT INFORMATION GENERAL INFORMATION. Sex: M F Age Birthdate. Date. Name. Relationship to Patient
PATIENT INFORMATION Name Address City State Zip Sex: M F Age Birthdate Single Married Significant Other Widowed Separated Divorced Patient SS# Occupation Employer Emp. Address Emp. Phone Spouse/Partner
Application Form. New application Change my current plan/deductible. Add spouse/partner/dependents Reinstatement
Application Form Important: Please make sure all the information required on this health insurance application has been provided. Best Doctors Insurance Limited reserves the right to contact the if a question
Questions and answers on serious non-fatal adverse events and reporting rules
18 April 2013 EMA/CVMP/PhVWP/303762/2012 Committee for Medicinal Products for Veterinary Use Questions and answers on serious non-fatal adverse events and reporting rules This question and answer document
Mortality statistics and road traffic accidents in the UK
Mortality statistics and road traffic accidents in the UK An RAC Foundation Briefing Note for the UN Decade of Action for Road Safety In 2009 2,605 people died in road traffic accidents in the UK. While
POLICY TERMS AND CONDITIONS
page 1 DEFINITIONS INSURER Praetorian Insurance Company, New York, NY as named on the document of insurance. INSURED The person(s) named on the document of insurance. PET The insured s pet named on the
Pathology ICD-10-CM Coding Tip Sheet Overview of Key Chapter Updates for Pathology and Top 25 codes
Pathology ICD-10-CM Coding Tip Sheet Overview of Key Chapter Updates for Pathology and Top 25 codes Chapter 2 Neoplasms (C00-D49) Classification improvements Code expansions Significant expansions or revisions
Hospital-based SNF Coding Tip Sheet: Top 25 codes and ICD-10 Chapter Overview
Hospital-based SNF Coding Tip Sheet: Top 25 codes and Chapter Overview Chapter 5 - Mental, Behavioral and Neurodevelopmental Disorders (F00-F99) Classification improvements (different categories) expansions:
PATIENT SELF-ASSESSMENT FORM
PATIENT SELF-ASSESSMENT FORM Please complete the information below to the best of your ability. Personal Information Name: Address: City: State: Zip: Telephone: Email: Name of referring physician: Address:
Patient Information. Patient s First and Last name: Preferred Name: Mailing Address: City: State: Zip Code: Date of Birth: Gender:
Patient Information: Patient Information Patient s First and Last name: Preferred Name: Mailing Address: Date of Birth: Gender: Best Number to Confirm Your Appointments: Alternate Phone Number: Social
5 Burden of disease and injury
5 Burden of disease and injury 5.1 Overview In this chapter, we present the results of the Australian Burden of Disease and Injury Study for the total disease burden measured in by age, sex and cause for
INDIVIDUAL LIFE INSURANCE APPLICATION PART II - MEDICAL EXAMINATION
INDIVIDUAL LIFE INSURANCE APPLICATION PART II - MEDICAL EXAMINATION ReliaStar Life Insurance Company, 20 Washington Avenue South, Minneapolis, MN 55401 Security Life of Denver Insurance Company, 1290 Broadway,
NEW PATIENT INFORMATION FORM
Woosik M. Chung, M.D. Timothy R. Kuklo, M.D., J.D. 303-762-DISC (3472) NEW PATIENT INFORMATION FORM Please print all information. By fully completing this form, you allow us to serve you quickly and efficiently.
Patient Interview Form
Patient Interview Form www.austingastro.com Patient Information First Name: Date Of Birth: Last Name: Age: Email Please check one as your preferred email for communications Personal: Work: Race Select
BREAST HEALTH HISTORY FORM
BREAST HEALTH HISTORY FORM Name Date of Visit: Date of Birth: Age: REFERRING PHYSICIANS: please include name, address and phone number of all physicians whom you would like to receive report of today s
Workman s Compensation
Workman s Compensation Name: Sex: Phone Number: Age: Address (Street/City/State/Zip) Name of Employer: Phone: Address of Employer (Street/City/State/Zip) Date and time of accident?: Where were you taken
More details >>> HERE <<<
More details >>> HERE http://urlzz.org/conitp/pdx/cc8648/ Tags:
How to Remove a Social History Smoke?
AUSTIN RETINA ASSOCIATES PATIENT INFORMATION NAME: MAILING ADDRESS or NURSING HOME NAME & ADDRESS: Last First Middle Initial CITY: STATE: ZIP CODE: - TELEPHONE: HOME:( ) CELL: ( ) WORK:( ) DATE OF BIRTH:
Limited Pay Policy (L-222B) - Underwriting Guidelines
Limited Pay Policy (L-222B) - Underwriting Guidelines 1 Addiction/Abuser Drug - Past or Present Presently Recovered - AA for last 2 years 2 Aids 3 Alcoholic Presently Recovered - AA for last 2 years 4
Sports Health Insurance. application for sports players
Sports Health Insurance application for sports players Here to Help We hope you will find this application form easy and straightforward to complete but if you require any assistance the General & Medical
Feline Lower Urinary Tract Disease (FLUTD)
Feline Lower Urinary Tract Disease (FLUTD) VETERINARY GUIDE 2 What is FLUTD? FLUTD describes a collection of common conditions that affect the bladder and/or urethra the narrow tube that carries urine
*3451 BARIATRIC SERVICE HEALTH QUESTIONNAIRE
BARIATRIC SERVICE HEALTH QUESTIONNAIRE Name: Male Female Address: City: State: Zip: Home Phone: ( ) E-Mail: Mobile Phone: ( ) Primary Language: Religious Preference : Education Level: Date of Birth: Social
RIDGE PHYSICAL THERAPY & WELLNESS CENTER. Intake Form
Intake Form : Personal Information please print clearly Name: last first middle initial Home Address: Home Telephone: ( ) Cell Phone: E-Mail Address: Social Security #: of Birth: Age: Sex: M F Marital
LYMPHOMA IN DOGS. Diagnosis/Initial evaluation. Treatment and Prognosis
LYMPHOMA IN DOGS Lymphoma is a relatively common cancer in dogs. It is a cancer of lymphocytes (a type of white blood cell) and lymphoid tissues. Lymphoid tissue is normally present in many places in the
PART A GENERAL INFORMATION
Flexcare Application for Quebec Residents The Manufacturers Life Insurance Company AIR MILES Collector #: 8 WSE *All applicants must complete parts A, B, C, D PART A GENERAL INFORMATION Applicant s First
1MFBTF GJMM PVU GPSNT BOE GBY 'PSNT XJMM CF TJHOFE BU ZPVS BQQPJOUNFOU
CELL PHONE: PATIENT HISTORY FORM - CONFIDENTIAL DATE: PATIENT: (LAST NAME) (FIRST NAME) (Ml) (NICKNAME) DOB: Primary Physician/ Family Doctor: Phone: Past Medical History (Click all that apply) High blood
Denver Spine Surgeons David Wong, MD, Sanjay Jatana, MD, Gary Ghiselli, MD
Cervical and Lumbar Spine Health History Name: Today s Date: Referring Provider: How did you find us: (Please circle) Primary care physician, Google search, Facebook, Friend or Family member, Website (JatanaSpine
Rheumatology Associates of North Jersey New Data Sheet
Personal History Rheumatology Associates of North Jersey New Data Sheet To our new patients: Welcome to our practice. SS: - - Date: Last Name: First Name Date of Birth / / Age Address City State Zip Code
List of Qualifying Conditions
List of Qualifying Conditions Cancer Conditions 1) Adrenal cancer 2) Bladder cancer 3) Bone cancer all forms 4) Brain cancer 5) Breast cancer 6) Cervical cancer 7) Colon cancer 8) Colorectal cancer 9)
PHC4 35 Diseases, Procedures, and Medical Conditions for which Laboratory Data is Required Effective 10/1/2015
PHC4 35 Diseases, Procedures, and Medical Conditions for which Laboratory Data is Required Effective 10/1/2015 Laboratory data is to be submitted for discharges in the following conditions: 1. Heart Attack
OrthoVirginia Registration Information 2016
OrthoVirginia Registration Information 2016 Patient Information Patient Name Account # Home Telephone # Work Telephone # Social Security Number Cell Telephone # Address Patient Sex Male Female City, State
TALLAHASSEE EYE CENTER
TALLAHASSEE EYE CENTER PATIENT INFORMATION Date: Name: Gender: M / F First MI Last Date of Birth: / / Address: City: State: ZIP: Phone Numbers: Home: Cellular: Work: E-Mail: SS#: - - What is the best way
CLINIC APPLICATION. Client Information
ICNA Relief USA Shifa Free Medical Clinic 1092 Johnnie Dodds Boulevard, Suite 108 Mount Pleasant, SC 29464 Tel: (843) 352-4580 Fax: (843) 375-9063 Last Name Street Address City, State, Zip Code Home Phone
Asteron Life Business Insurance
Asteron Life Business Insurance What lump sum covers are available with Asteron Life Business Insurance? Life Cover Life Cover pays a lump sum of money if you pass away or become terminally ill. Total