MELISA Questionnaire for Autistic Children
|
|
|
- Aldous Cain
- 7 years ago
- Views:
Transcription
1 MELISA Questionnaire for Autistic Children The MELISA Medica Foundation is dedicated to the study of metal allergy, a condition which can be a risk factor in many diseases. In allergic children, not only skin but any other organ, including the brain, may be affected by metal-induced inflammation. Theoretically, vaccine additives such as thimerosal or aluminum could trigger such reactions. This questionnaire may help you to identify present and past exposure of your child to environmental pollutants, especially mercury. Mercury is implicated by some researchers as a riskfactor in the development of autism and other psychiatric disorders. The possibility that your child suffers from metal hypersensitivity will also be examined. PERSONAL INFORMATION Name of parent(s): Child s family name: Given names: Date of birth: Date diagnosed as autistic (month/year): Date of birth of parents: Mother: Father: Address: Daytime telephone number: Throughout this questionnaire, you means the mother. Please circle the correct answer. 1. HEALTH OF YOUR CHILD 1.1 Was your child born healthy? If not, please detail 1.2 Child s APGAR score at birth: 1.3 Developmental landmarks (please approximate the age): Crawling: Delayed in your opinion? Sitting: Delayed in your opinion? Walking: Delayed in your opinion? Talking: Delayed in your opinion?
2 1.4 Did any of the previous landmarks change post-vaccination? If so, what changed and how long after vaccination? 2. VACCINATION HISTORY (This field is very important. Please give type of vaccine, date, and, if possible, the manufacturer). 3. LABORATORY TESTS Have you sent hair, blood or any other sample of your child to a laboratory for testing? If so, please give details. If you have tested for the presence of heavy metals, it would be helpful if you could indicate if any provocation agent was used, such as DMSA or DMPS. 4. ILLNESSES AND ALLERGIES 4.1 Please detail the symptoms of autism/delayed development detected in your child.
3 4.2 Does your child suffer from any respiratory/breathing problems? 4.3 Does your child suffer from digestive problems such as gas, bloating, "tummy aches", cramping, chronic diarrhea, constipation, food sensitivities? If yes, please describe: 4.4 Has your child ever had skin lesions/eczema/rashes of any kind? 4.5 Is your child's skin irritated by any forms of metal (for example, jeans fasteners, costume jewelry, earrings etc)? 4.6 Does your child take any medication?
4 4.7 Does your child take any minerals or vitamins? If yes, please detail: 5. SOURCES OF EXPOSURE TO METALS 5.1 Does your child have any silver/mercury dental fillings? If so, how many? When were they placed? 5.2 Does you child wear dental braces? If yes, when were they fitted? 5.3 Does your child have any white fillings? If yes, since when and how many? 6. THE MOTHER: SOURCES OF METAL EXPOSURE 6.1 Do you have silver/mercury fillings? If yes, approximately how many? 6.2 Did you have the same number of fillings during your child's pregnancy? 6.3 Did you have dental treatment during your pregnancy? 6.4 Was the child breastfed?
5 6.5 Did you have other dental metals fitted (i.e. titanium, stainless steel, gold, metal based ceramics)? Did you during the pregnancy? During breastfeeding? If yes, please specify: 6.7 Were you given any vaccinations prior or during pregnancy/breastfeeding? If yes, please list: Date Vaccination Manufacturer (if known) 6.8 Did you use any creams (especially those containing mercurochrome) against varicose veins or against eczema prior or during pregnancy and breastfeeding? 6.9 Did you receive Rhogam injections (for RH-negative mothers) just after childbirth? If yes, please specify when the injection took place: 6.10 Are you allergic to make-up and cosmetics? 6.11 Did you use eye drops during pregnancy or breastfeeding?
6 6.12 Are you allergic to any medication? 6.13 Were you taking antibiotics prior to or during pregnancy/breastfeeding? 6.14 Did you live near a factory, industry, coal smelter, crematorium, highway or airport prior or during the pregnancy? If yes, please specify: SMOKING 6.15 Have you ever been a regular smoker? Please give details (how many cigarettes a day, and for how long) 6.16 Did you smoke during pregnancy? 6.17 Were you passively exposed to smoke during pregnancy? 6.18 Were you or your child involved in a car accident or another serious accident which may have led to brain concussion (such as falling, stumbling, etc)? If yes, please specify 7. FAMILY HEALTH AND EXPOSURE 7.1 Do any brothers or sisters of your child have autism, learning difficulties or other psychiatric disorders? If yes, which ones and how old are they? continue on separate page if necessary)
7 7.2 Did your family used to drink water from your own well, or private supply? (Some families who live in rural area may not have access to the central water network) If yes, do you know the content of minerals/pollutants in this water? If yes, what was the result? 8. YOUR FAMILY S HEALTH 8.1 Please indicate if any of following medical conditions occurred in your family, child's father family or in the child s brothers or sisters. Please give the family member. Allergies: Autoimmune diseases (like rheumatoid arthritis, multiple sclerosis etc): _ Skin diseases: Heart/artery diseases: Diabetes: Cancers/tumors: Chemical sensitivity: Psychiatric illnesses (including old-age conditions such as Parkinson s, Alzheimer s and dementia): Other: (continue on separate page if necessary) 8.2 Is there any other information which you feel is relevant to the condition of your child? Please give any thoughts that you may have:
8 If you needed extra space, please continue your answers on separate papers, stating clearly which question you are answering. COPYRIGHT Prof. Vera Stejskal and Dr Deborah Baker. MELISA is a registered trademark. Please return this form, either by fax or post, to Prof. Vera Stejskal. If you are online, please send an to info@melisa.org to inform us that the fax has been sent. Or you can telephone on to MELISA Diagnostics Ltd, United Kingdom. Prof. Vera Stejskal, MELISA Medica Foundation, August Wahlströms väg 10, , Danderyd, Stockholm, Sweden. Fax: For a donation of US$50 your questionnaire will be reviewed by Prof. Stejskal and the evaluation sent back to you within 14 days. For maximum safety send your credit card information by fax. Your credit card information Credit Card number: Credit Card Expiration Date: month year CVS: _ I agree to let you debit US$50 to my credit card as a donation for research to the MELISA Diagnostics (on behalf of the MELISA Medica Foundation) Please sign below Place: Date: I want the evaluation of the questionnaire sent to me by: (check the box of your choice) Mail Fax
Mortgage Protection Plan/Level Term Plan With/Without Critical Illness Cover
Metropolitan Police Friendly Society Berwick House, 8-10 Knoll Rise, Orpington, Kent, BR6 0EL Despatch: MPFS Orpington - Phone: 01689 891454 - Metphone: 2 Email: enquiries@mpfs.org.uk - Web: www.mpfs.org.uk
HAIR LOSS QUESTIONNAIRE
NAME DATE HAIR LOSS QUESTIONNAIRE Please tell me more about your hair loss condition by answering the following questions. For some questions you will need to mark the YES or NO box at the right. For other
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
First Name. Profession. Weight lbs. Weight 1 year ago lbs. Min. Adult Weight lbs. at age Maximum Weight lbs. at age
Date Time Dietary consultation involves a health profile whose purpose is not to establish a diagnosis, but rather to determine a client's health status in order to guide his or her weight loss plan. A
How To Write A Recipe Card
Joanne R. Festa, PhD (PLEASE PRINT) NAME: DATE OF BIRTH: NEUROPSYCHOLOGY INITIAL VISIT DATE: AGE: Do you have any areas of concern about your cognitive functioning? (i.e., problems with memory, attention,
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
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
Child and Adolescent Developmental Questionnaire
Child and Adolescent Developmental Questionnaire Child s Name:. Age Date of Birth Person completing this form: Relationship: Sex: M / F Date: Current Problems What is the # 1 concern causing you to seek
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
Information for you Treatment of venous thrombosis in pregnancy and after birth. What are the symptoms of a DVT during pregnancy?
Information for you Treatment of venous thrombosis in pregnancy and after birth Published in September 2011 What is venous thrombosis? Thrombosis is a blood clot in a blood vessel (a vein or an artery).
Life Insurance Plans Application Forms
You can either complete this form here on screen or print it off and complete it by hand. Either way you will need to print it off, sign it and physically post it to us through Despatch or via Royal Mail.
San Ramon Valley Primary Care Medical Group Internal Medicine Patient Information Sheet
San Ramon Valley Primary Care Medical Group Internal Medicine Patient Information Sheet By completing this questionnaire you provide us with important, basic information for our records. Please print your
CONSENT FOR MRI SCAN WITH INTRAVENOUS CONTRAST
CONSENT FOR MRI SCAN WITH INTRAVENOUS CONTRAST Your Doctor has asked that an MRI scan be performed using intravenous contrast. This contrast may give the radiologist additional information that may not
NEUROPSYCHOLOGY QUESTIONNAIRE. (Please fill this out prior to your appointment and bring it with you.) Name: Date of appointment: Home address:
NEUROPSYCHOLOGY QUESTIONNAIRE (Please fill this out prior to your appointment and bring it with you.) Name: Date of appointment: Date of birth: Age: _ Home address: _ Home phone: Cell phone: Work phone:
Women s Continence and Pelvic Health Center
Women s Continence and Pelvic Health Center Committed to Caring 580-590 Court Street Keene, New Hampshire 03431 (603) 354-5454 Ext. 6643 URINARY INCONTINENCE QUESTIONNAIRE The purpose of this questionnaire
Goiter. This reference summary explains goiters. It covers symptoms and causes of the condition, as well as treatment options.
Goiter Introduction The thyroid gland is located at the base of your neck. If the gland becomes abnormally enlarged, it is called a goiter. Goiters usually do not cause pain. But a large goiter could cause
Pitcairn Medical Practice New Patient Questionnaire
/ / *Areas are mandatory. Failure to complete may delay the time taken to process your registration *Surname: *Forename(s): *Address: *Date of Birth/CHI: / Marital Status: Sex: Male / Female (delete as
W. Daniel Williamson, M.D. and Anson J. Koshy, M.D. Developmental Pediatricians Dan L. Duncan Children s Neurodevelopmental Clinic Children s
W. Daniel Williamson, M.D. and Anson J. Koshy, M.D. Developmental Pediatricians Dan L. Duncan Children s Neurodevelopmental Clinic Children s Learning Institute University of Texas Health Science Center
Life Insurance Plan Application form
Life Insurance Plan Application form Applicant One Mr/Mrs/Ms/Miss Surname Forename(s) Date of Birth Gender M F Height Weight Do you smoke, or have you in the last 12 months? Yes No If yes, how many do
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
LITTLE ELM MEDICAL CLINIC S PATIENT DEMOGRAPHIC INFORMATION
A-02 form.patient.demographic.information Rev. (01/14) DATE: SIGNATURE: PHYSICIAN (PLEASE PRINT) LITTLE ELM MEDICAL CLINIC S PATIENT DEMOGRAPHIC INFORMATION PATIENT'S FULL NAME ADDRESS APT. # CITY STATE
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
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
Life Insurance Application Form
Life Insurance Application Form INSTRUCTION To be completed by all applicants PERSONAL DETAILS Surname First name Middle name Sex Female Male Marital status (please tick) Single Married Other Current residential
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
FAQs on Influenza A (H1N1-2009) Vaccine
FAQs on Influenza A (H1N1-2009) Vaccine 1) What is Influenza A (H1N1-2009) (swine flu) 1? Influenza A (H1N1-2009), previously known as "swine flu", is a new strain of influenza virus that spreads from
Danita Thomas Heagy, DC, LLC 4425 US 1 South, Suite 109 St Augustine FL 32086-3127 904-797-5100 www.drdanita.com
WELCOME! Thank you for choosing this office to assist you with your health care. Once the exam is complete, I will present my findings and recommendations to you briefly. At the Health Dialogue, we will
Bowel Control Problems
Bowel Control Problems WOMENCARE A Healthy Woman is a Powerful Woman (407) 898-1500 Bowel control problems affect at least 1 million people in the United States. Loss of normal control of the bowels is
Section 2. Health Questionnaire
Section 2 Health Questionnaire Health Management Toolkit Reference 2.0 Information on Step 2: Employee Health Questionnaire Many cases of ill health can go unreported in the workplace, which can put the
3-1 THE NERVOUS SYSTEM
C A S E S T U D Y 3 : T o d d l e r Adapted from Thomson Delmar Learning s Case Study Series: Pediatrics, by Bonita E. Broyles, RN, BSN, MA, PhD. Copyright 2006 Thomson Delmar Learning, Clifton Park, NY.
Lesson 7: Respiratory and Skeletal Systems and Tuberculosis
Glossary 1. asthma: when the airways of the lungs narrow, making breathing difficult 2. bacteria: tiny living creatures that can only be seen with a microscope; some bacteria help the human body, and other
Neuropsychological Testing Appointment
Neuropsychological Testing Appointment Steven A. Rogers, PhD Kathleen D. Tingus, PhD 1701 Solar Drive, Suite 140 Oxnard, CA 93030 When will it be? Date: Time: Examiner: What will I have to do? Each appointment
Background Information & Medical History Form
Background Information & Medical History Form To ensure you receive a complete and thorough evaluation, please provide us with information regarding your health status found on this form. If you do not
There Are Millions of People at Risk For Dry Eye Who Is Likely to Develop This Irritating Condition?
There Are Millions of People at Risk For Dry Eye Who Is Likely to Develop This Irritating Condition? Dry eye can be a temporary or chronic condition and occurs when the eye does not produce tears properly,
NEUROSURGERY SERVICES AT APD LOCATED AT UPPER VALLEY MEDICAL GROUP 106 Hanover Street, Lebanon, NH 03766 Phone: 603.448.0447 Fax: 603.448.
DATE NEUROSURGERY SERVICES AT APD LOCATED AT UPPER VALLEY MEDICAL GROUP 106 Hanover Street, Lebanon, NH 03766 Phone: 603.448.0447 Fax: 603.448.0019 Joseph M. Phillips, M.D., Ph.D. Board Certified in Pain
Name: Birthdate: Age: Address: City, State, ZIP: Preferred Phone # (Home)(Cell)(Work): Marital Status: M S W D
Be Fit Physical Therapy & Pilates, LTD Patient Registration Form Date: Name: Birthdate: Age: Address: City, State, ZIP: Preferred Phone # (Home)(Cell)(Work): Marital Status: M S W D Secondary Phone# (Home)(Cell)(Work):
Health History Form: Beverly Hosford, Muscle Activation Techniques Specialist
Health History Form: Beverly Hosford, Muscle Activation Techniques Specialist Name: Phone: Address: E-mail: Birthdate: Age: EMERGENCY CONTACT Name: Phone: Are you seeing any medical practitioners such
Fortrose Medical Practice
Fortrose Medical Practice GP Partners: Dr Sandy MacGregor, Dr Will Fraser, Dr Iain Forth & Dr Jude Watmough Associate GP: Dr Shona Forth Station Road Fortrose Ross-shire IV10 8SY Phone: Fax: Email: Website:
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:
Chapter 3 Type 1 Diabetes
Chapter 3 Type 1 Diabetes Type 1 diabetes is one of the most common chronic disorders of childhood. Unfortunately, it is increasing in incidence, particularly in young children. The reason for this is
DENVER CHIROPRACTIC CENTER GLENN D. HYMAN, DC, CSCS
DENVER CHIROPRACTIC CENTER GLENN D. HYMAN, DC, CSCS Are you in the right place? Please read this before proceeding with paperwork: At Denver Chiropractic Center, we specialize in treating muscles with
Male Patient Questionnaire & History
Male Patient Questionnaire & History Name: Today s Date: (Last) (First) (Middle) Date of Birth: Age: Occupation: Home Address: City: State: Zip: E- Mail Address: May we contact you via E- Mail? ( ) YES
PARTNERS IN PEDIATRIC CARE. Intake and History for Mental Health Referral
PARTNERS IN PEDIATRIC CARE Intake and History for Mental Health Referral This form is designed to give you an opportunity to provide us with background information that will help us help you. Please read
2. Timeliness: If you are more than 15 minutes late, we may ask you to reschedule your appointment.
Welcome to our clinic! Our goal at University of Wisconsin Hospital & Clinics is to offer the best possible care to our patients. We want to work with you to make that happen. To best work as a health
PEDIATRIC - CASE HISTORY FORM
Thank you, for choosing Access Rehab Centers. We kindly request that you fill out all the necessary information for our therapists to complete a comprehensive evaluation of your child. Please mail this
Figure 14.2 Overview of Innate and Adaptive Immunity
I M M U N I T Y Innate (inborn) Immunity does not distinguish one pathogen from another Figure 14.2 Overview of Innate and Adaptive Immunity Our first line of defense includes physical and chemical barriers
Prescription Drug Plan
Prescription Drug Plan The prescription drug plan helps you pay for prescribed medications using either a retail pharmacy or the mail order program. For More Information Administrative details and procedures
Physician address. Physician phone
PATIENT QUESTIONNAIRE Name (first, middle initial, last) Address City, State, Zip Social security number Michigan SportsMedicine and Orthopedic Center www.michigansportsmedicine.com Your family physician
SPEECH AND LANGUAGE CASE HISTORY FORM PLEASE ATTACH A RECENT PHOTO OF YOUR CHILD HERE IDENTIFYING INFORMATION
SPEECH AND LANGUAGE CASE HISTORY FORM Date Person filling out this questionnaire Relationship to child PLEASE ATTACH A RECENT PHOTO OF YOUR CHILD HERE IDENTIFYING INFORMATION Name of child Nickname Date
PRIMARY CARE ASSOCIATES MASS GENERAL WEST NEW PATIENT QUESTIONNAIRE
PRIMARY CARE ASSOCIATES MASS GENERAL WEST NEW PATIENT QUESTIONNAIRE Name: DOB: Date completed: Where have you received health care previously? Do you require a translator? Yes No Do you have any hearing,
MINISTRY OF HEALTH PANDEMIC INFLUENZA A / H1N1 2009 VACCINE FREQUENTLY ASKED QUESTIONS
Government of the Republic of Trinidad and Tobago MINISTRY OF HEALTH PANDEMIC INFLUENZA A / H1N1 2009 VACCINE FREQUENTLY ASKED QUESTIONS Influenza vaccines are one of the most effective ways to protect
New River Health will bill private insurance, Medicaid, and CHIP for eligible students. No child will be denied services due to inability to pay.
The Richwood School-Based Health Center is pleased to offer medical, mental health counseling, health education, and on site dental services to all Richwood Middle School and Richwood High School students.
Bladder Control Does Matter
Bladder Control Does Matter Y0028_2726_0 File&Use 04092012 If you suffer from urinary incontinence, you re not alone Don t be afraid to raise your hand if you ve been struggling with the embarrassment
Male New Patient Package
Male New Patient Package The contents of this package are your first step to restore your vitality. Please take time to read this carefully and answer all the questions as completely as possible. Thank
Raynaud s Disease. What is Raynaud s Disease? Raynaud s disease is also sometimes known as Raynaud s phenomenon or Raynaud s syndrome.
Raynaud s Disease Introduction Raynaud s disease is a rare disorder of the blood vessels. It usually affects the fingers and toes. This disorder causes the blood vessels to narrow which turns the affected
NEW PATIENT CLINICAL INFORMATION FORM. Booth Gardner Parkinson s Care & Movement Disorders Center Evergreen Neuroscience Institute
NEW PATIENT CLINICAL INFORMATION FORM Booth Gardner Parkinson s Care & Movement Disorders Center Evergreen Neuroscience Institute Date: Name: Referring Doctor: How did you hear about us? NWPF Your Physician:
Dental Admission Form
Dental Admission Form PERSONAL HISTORY All of the information which you provide on this form will be held in the strictest confidence. Although some questions may seem unimportant at the time, they may
ORTHOPAEDIC SPINE PAIN QUESTIONNAIRE
ORTHOPAEDIC SPINE PAIN QUESTIONNAIRE NAME: DATE: ADDRESS: AGE: TELEPHONE#: RELIGION: OCCUPATION: REFERRED BY WHOM: NEAREST FRIEND/RELATIVE: TELEPHONE#: ADDRESS: PLEASE EXPLAIN WHY YOU HAVE COME TO SEE
PEDIATRIC MEDICAL HISTORY FORM
Patient s First and Last Name / / PEDIATRIC MEDICAL HISTORY FORM PRESENT HEALTH CONCERN (Reason for today s visit.) ALLERGIES List all allergies to medications, foods and/or other agents. Medication/Food/Other
Coping With Stress and Anxiety
Coping With Stress and Anxiety Stress and anxiety are the fight-and-flight instincts that are your body s way of responding to emergencies. An intruder crawling through your bedroom window in the dark
Key words: Vitamin D Production, Vitamin D Deficiency, and Vitamin D Treatment
Title: Vitamin D Author: Kerry Lynn Kuffenkam Date: 4-29-09 Key words: Vitamin D Production, Vitamin D Deficiency, and Vitamin D Treatment Abstract: Since the term Vitamin D contains the word vitamin most
Dear Parent: We look forward to meeting you and your child.
Dear Parent: Thank you for your interest in Montgomery Township s, Kid Connection Preschool Program. Kid Connection has many programs revolving around a 7:30am-6:00pm day, Monday-Friday. During the school
DIET AND ECZEMA IN CHILDREN
DIET AND ECZEMA IN CHILDREN It has been known for many years that what children eat may have an effect on their eczema. There has been an ever-increasing interest in the part that diet plays in the development
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):
Known Donor Questionnaire
Known Donor Questionnaire Your donor s answers to these questions will provide you with a wealth of information about his health. You ll probably need assistance from a health care provider to interpret
MILLRISE MEDICAL PRACTICE NEW PATIENT REGISTRATION/HEALTH QUESTIONNAIRE
MILLRISE MEDICAL PRACTICE NEW PATIENT REGISTRATION/HEALTH QUESTIONNAIRE PLEASE COMPLETE THIS FORM IN BLOCK CAPITALS. To register with the Practice please complete this questionnaire as fully as possible.
Ear Infections Asthma in childhood asthma in childhood
Asthma Ear Infections in childhood asthma in childhood Asthma in childhood is common and it can be serious. About one in six children (aged less than 15 years) in Western Australia are affected by asthma.
ASTHMA IN INFANTS AND YOUNG CHILDREN
ASTHMA IN INFANTS AND YOUNG CHILDREN What is Asthma? Asthma is a chronic inflammatory disease of the airways. Symptoms of asthma are variable. That means that they can be mild to severe, intermittent to
CAYUGA CENTER FOR HEALTHY LIVING Geoffrey E. Moore, MD FASCSM Shannan Simkin, NP Lisa Proctor, NP ISLAND HEALTH & FITNESS COMPLEX ITHACA, NY 14850
CAYUGA CENTER FOR HEALTHY LIVING Geoffrey E. Moore, MD FASCSM Shannan Simkin, NP Lisa Proctor, NP ISLAND HEALTH & FITNESS COMPLEX ITHACA, NY 14850 TELEPHONE: (607) 252-3590 FAX: 607-252-3592 An appointment
VEIN CLINIC OF NORTH CAROLINA 3318 HEALY DR. WINSTON SALEM, NC 27103 PH. 336-768-3530 FAX- 768-1329. Scott W. Baker, MD. Patient Instructions
18 HEALY DR. WINSTON SALEM, NC 710 PH. 6-768-50 FAX- 768-19 Scott W. Baker, MD Patient Instructions 1. Bring a list of all regular medications and dosages.. Bring your insurance card and all necessary
PAIN MANAGEMENT. Patient s name: IF YOUR INSURANCE REQUIRES A PRE AUTHORIZATION / REFERRAL FORM, PLEASE OBTAIN PRIOR TO YOUR VISIT.
PAIN MANAGEMENT Please fill out the following questionnaire and bring it with you to your appointment. In addition, bring your medication list and Reports of any X- rays, MRI or Cat scans. Patient s name:
BASIC INFORMATION ABOUT HIV, HEPATITIS B and C, and TUBERCULOSIS Adapted from the CDC
BASIC INFORMATION ABOUT HIV, HEPATITIS B and C, and TUBERCULOSIS Adapted from the CDC HIV What are HIV and AIDS? HIV stands for Human Immunodeficiency Virus. This is the virus that causes AIDS. HIV is
english facts about hepatitis A, B and C
english facts about hepatitis A, B and C What is hepatitis? Hepatitis means inflammation of the liver. Many viruses can cause liver inflammation, including the hepatitis A, B and C viruses. Some people
Seasonal Allergies. 1995-2012 The Patient Education Institute, Inc. www.x-plain.com im010101 Last reviewed: 05/30/2012 1
Seasonal Allergies Introduction Seasonal allergies are allergies that develop during certain times of the year. Seasonal allergies are usually a response to pollen from trees, grasses, and weeds. Constant
Holy Family University, Student Health Services, Directions for Completion of Health Packet
1 Holy Family University, Student Health Services, Directions for Completion of Health Packet All forms are to be returned to Health Services by Summer Orientation for the Fall Semester and the first day
X-Plain Preparing For Surgery Reference Summary
X-Plain Preparing For Surgery Reference Summary Introduction More than 25 million surgical procedures are performed each year in the US. This reference summary will help you prepare for surgery. By understanding
LOW T NATION TESTOSTERONE INTAKE FORM NAME: DATE: ADDRESS: CITY: STATE: ZIP: CELL #: HOME #: SOC SECURITY #: DATE OF BIRTH:
LOW T NATION TESTOSTERONE INTAKE FORM NAME: DATE: ADDRESS: CITY: STATE: ZIP: CELL #: HOME #: SOC SECURITY #: DATE OF BIRTH: DRIVERS LICENSE NUMBER: STATE: EMAIL ADDRESS: MARITAL STATUS: ( ) SINGLE ( )
Which flu vaccine should you or your child
have? Click on an age group to find out Birth to under six months Babies of this age cannot have flu vaccine so the best way to protect them is for their mother to have the vaccination while pregnant.
General Internal Medicine Clinic New Patient Questionnaire
General Internal Medicine Clinic New Patient Questionnaire Date: Name: What would you like to be called by the doctor? Marital Status: Please list how you would like to be contacted, for test results:
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
Grey Physical Therapy and Sports Medicine Center
Grey Physical Therapy and Sports Medicine Center 101 Phoenix Ave, 2D Body Made Better by Grey A Tradition of Caring Since 1984 Enfield, CT 06082 Ph (860) 741-2541 F (860) 745-5264 Patient Information First
PATIENT INFORMATION SHEET KEY FACTS
PATIENT INFORMATION SHEET KEY FACTS Please read this carefully and refer to the full information sheet You are invited to take part in a research study, comparing subcutaneously (injection under skin)
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
Thank you for choosing the Rubin Institute for your orthopedic care. We are looking forward to seeing you soon!
Dear New Patient, Welcome to the Rubin Institute for Advanced Orthopedics! Our goal is to provide you with caring, compassionate and professional service during your visit with us. If you have any questions,
Developing Human Fetus
Period Date LAB. DEVELOPMENT OF A HUMAN FETUS After a human egg is fertilized with human sperm, the most amazing changes happen that allow a baby to develop. This amazing process, called development, normally
Medicare Patient Information. Patient Name: SS#: - - Date of Birth: / / Sex: Female Male. City: State: Zip Code:
Medicare Patient Information Patient Name: SS#: - - Date of Birth: / / Sex: Female Male Address: Street: City: State: Zip Code: Home Phone: ( ) - Work/Mobile Phone: ( ) - Please print your name as it Appears
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
My health action plan
My health action plan Contents What is a health action plan? 3 Section 1 Personal information 7 Section 2 People who help me 13 Section 3 Communication 17 Section 4 Medicine 23 Section 5 My general health
Tennessee State University Department of Speech Pathology & Audiology Intensive Articulation, Fluency, Language & Diagnostics Summer Speech Camp
Tennessee State University Department of Speech Pathology & Audiology Intensive Articulation, Fluency, Language & Diagnostics Summer Speech Camp Speech Pathology and Audiology will provide intensive therapeutic
WELCOME PATIENT CONDITION
NATURAL CARE WELLNESS CENTER 6 SEELEY LANE, ELIOT, ME 03903 WELCOME PATIENT CONDITION PATIENT INFORMATION Date Reason for Visit SS# Patient Name Last Name First Name Middle Initial Address Do you suffer
Sleep History Questionnaire
Sleep History Questionnaire Name Address Daytime Phone Height Evening Phone Weight Weight 5yrs ago Describe your sleep problem: 1. What time do you go to bed? 2. What time do you wake up? 3. What time
Chickenpox in pregnancy: what you need to know
Chickenpox in pregnancy: what you need to know First published December 2003 Revised edition published November 2008 What is chickenpox? Chickenpox is a very infectious illness caused by a virus called
http://images.tutorvista.com/content/control5coordination/human5brain.jpeg!! 387
http://images.tutorvista.com/content/control5coordination/human5brain.jpeg!! 387! 388! http://my.fresnounified.org/personal/lygonza/gonzalez/neuron/neuron5synapse%20communication.png!! http://www.urbanchildinstitute.org/sites/all/files/databooks/2011/ch15fg25communication5between5neurons.jpg!!
Name (Full Given Name(s) and Family Name)
Queensland Government Coal Mine Workers Health Scheme - Health Assessment Form Section 46 Coal Mining Safety and Health Regulation 2001 Form Number CMSHR 1 (Form approved by Chief Inspector under section
Suspected pulmonary embolism (PE) in pregnant women
Suspected pulmonary embolism (PE) in pregnant women What is a pulmonary embolus? A deep vein thrombosis (DVT) is a blood clot that forms in one of the deep veins of the leg. If the clot moves to the lung,
Protecting your child against flu
Protecting your child against flu Information for parents Flu mmunisation 2015/16 Helping to protect everyone, every winter This year, the flu vaccine is being offered to: children aged two, three and
Combination Birth Control Pills - FAQ
Combination Birth Control Pills - FAQ How does the birth control pill work? prevents ovulation thickens cervical mucus, which makes it hard for sperm to enter the uterus thins the lining of the uterus,
Patient Questionnaire for Men
Patient Questionnaire for Men Please fill out the following questionnaire to the best of your ability prior to your first appointment. Your physical therapist will review your responses during your initial
Lesson 3 Managing Food Allergies
Lesson 3 Managing Food Allergies Lesson at a Glance Time Allowed (1 hour) 5 minutes Introduction to Managing Food Allergies 15 minutes Objective 1: Creating a Food Allergy Policy Topic Activity Materials
Medical Massage Client Intake Form Medical Massage Client Intake Form
Medical Massage Client Intake Form Medical Massage Client Intake Form Client Name: Date: Please note: The more information you are able to provide, the better equipped our therapists will be to help you.