ALLERGY, ASTHMA, IMMUNOLOGY OF ROCHESTER, P.C. CHRONIC URTICARIA (HIVES) QUESTIONNAIRE
|
|
|
- Conrad Jones
- 7 years ago
- Views:
Transcription
1 ALLERGY, ASTHMA, IMMUNOLOGY OF ROCHESTER, P.C. CHRONIC URTICARIA (HIVES) QUESTIONNAIRE Patient Name: Date: DOB: I. General Features A. Date of onset of hives B. Frequency of attacks (i.e. daily, weekly, etc) C. Duration of attacks D. Time of day when symptoms most severe 1. mornings 2. daytime 3. evenings 4. after meals 5. other E. Parts of body usually affected first, if any II. Seasonal Do hives occur more frequently during certain times of the year? A. Winter B. Cold exposure (wind, swimming, etc.) C. Spring (pollens) D. August-September (ragweed) E. Summer III. Physical Do any of the following produce hives? A. Heat exposure B. Exercise C. Sunlight exposure D. Rainy or wet periods E. Damp rooms/areas (molds) F. Bathing or showering G. Pressure, prolonged sitting H. Vibration I. Rubbing or scratching J. Friction, clothing contact 1
2 IV. Contact A. Exposure to animals Which types? B. Exposure to fumes Which types? C. Contact with cosmetics, soaps, detergents, etc.? Which types? V. Hormonal A. Related to stress B. Menstrual periods C. Pregnancy VI. VII. Occupational-Recreational History Do hives appear to occur in relation to any of the following? A. Indoors only or predominantly Rooms/locations in particular 1. Workshop 2. Basement 3. Attic 4. Other B. Outdoors only or predominantly C. At work predominantly D. At home predominantly E. At another location Where? F. During work week predominantly G. On wekends predominantly H. Improve while away on vacation I. Related to recreational activities Which types? J. Occur with housework History of Infections Have you recently had any of the following infections or symptoms of infection? A. Sore throat/strep throat B. Swollen lymph glands C. Mononucleosis D. Impetigo/skin infections E. Jaundice/hepatitis Page 2 of 5
3 F. Pneumonia G. Yeast Infection H. Painful urination/urinary tract infection I. Infection of gall bladder J. Fungal infection of skin, hair or nails K. Tooth/gum infection L. Other VIII. History of Allergy or Allergic Symptoms Do you have any of the following types of allergy or allergic symptoms? A. Hay fever/sinus congestion B. Wheezing/asthma C. Itching of skin D. Eczema E. Excessive tearing F. Nausea/abdominal pains/diarrhea G. Swelling of lips or mouth after eating H. Known allergic agents I. Previous skin testing for allergies J. Family history of above problems IX. Medications A. List all prescription drugs taken in last year, including those discontinued. Please include any topical (creams) and injected medications. B. List all over-the-counter drugs taken in the last year. Please include cosmetics in this list. C. Check list of medications used in last year. Antibiotics Pain Killers Antidepressants Penicillin Antihistamines Sedatives Cortisone Seizure medication Cough medication Sleeping pills Decongestants Sulfa drugs Page 3 of 5
4 Diet pills Digitalis Diuretics Douches Hormones Laxatives Mouth washes Muscle relaxants Oral contraceptives Suppositories Tetracycline Thyroid pills Tonic (quinine) Tranquilizers Vaginal medication Water pills Vitamins D. For which of the following conditions have you taken medication in the last year? Acne Headaches Allergy Heart condition Anemia Hemorrhoids Arthritis Hypertension Asthma Indigestion Bowel disorder Insomnia Colds Kidney disorder Constipation Menopause Cough Menstrual disorder Depression Nervousness Diabetes Pinworms Diarrhea Rectal disorder Epilepsy Seizures Fungal infection Sinus trouble Gall bladder Thyroid disorder Glaucoma Urinary infection Gout Vaginal infection X. Foods A. Have you noticed that particular foods cause hives, swelling of lips or tongue, sinus congestion, nausea, abdominal pain or difficulty breathing? Please list foods and accompanying symptoms. B. Are any of the above symptoms caused by the following foods? Beer Milk Bread Mints Cake Nuts Page 4 of 5
5 Cheese Cider Coffee Eggs Grapes Ham/pork Ketchup Pickles Sausage Seafood Strawberries Tomatoes Wine Vinegar XI. Treatment Please indicate the treatments that have been used for your hives in the past. Use the following scale to score the response to each type of therapy: 0 - No response 1 - Slight response 2 - Moderate response 3 - Complete clearing Therapy Response A. Antihistamine B. Steroids (oral or injected) C. Epinephrine D. Ephedrine E. Dietary elimination-type F. Antibiotics G. Other - please specify Page 5 of 5
Questionnaire for patients with chronic urticaria (hives, wheals) and/or angioedema (deeply located swelling of the skin)
Questionnaire for patients with chronic urticaria (hives, wheals) and/or angioedema (deeply located swelling of the skin) Name:... male / female Birth date:... -... -... date:... -... -... Please answer
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
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
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:
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
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
DRUG INTERACTIONS: WHAT YOU SHOULD KNOW. Council on Family Health
DRUG INTERACTIONS: WHAT YOU SHOULD KNOW Council on Family Health Drug Interactions There are more opportunities today than ever before to learn about your health and to take better care of yourself. It
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
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.)
Application For Admission To The Non-Surgical Spinal Decompression Program At The Spinal Decompression Center of Long Beach
Application For Admission To The Non-Surgical Spinal Decompression Program At The Spinal Decompression Center of Long Beach If you are reading this form, you have qualified for a consultation with Dr.
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:
Douglas G. Benting, DDS, MS, PLLC Practice Limited to Prosthodontics
Douglas G. Benting, DDS, MS, PLLC Practice Limited to Prosthodontics Patient s Name Birthdate Who referred you to this office? Social Security # Address City ST ZIP Home Phone Work Phone Ext Cell Phone
BROCKTON AREA MULTI-SERVICES, INC. MEDICAL PROCEDURE GUIDE. Date(s) Reviewed/Revised:
Page 1 of 5 PROCEDURE FOR: MAP-certified staff and RN/LPN MAP-certified staff are to be trained in the use of epinephrine administration via pre-filled autoinjector devices(s) annually. Certified staff
THE AYURVEDIC CENTER OF VERMONT, LLC Health Information and History
THE AYURVEDIC CENTER OF VERMONT, LLC Health Information and History Name DOB Date Age Occupation Email Address Home address City State Zip Home phone Cell Phone Referred By Physician Physician Phone Please
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
Department of Allergy & Immunology
Department of Allergy & Immunology DR. DATE OF APPT. TIME Dear Patient: Please complete the enclosed questionnaire and bring it with you to the Clinic on the day of your appointment. If you have any questions,
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
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
CVP Chemotherapy Regimen for Lymphoma Information for Patients
CVP Chemotherapy Regimen for Lymphoma Information for Patients The Regimen Contains: C: Cyclophosphamide (Cytoxan ) V: Vincristine (Oncovin ) P: Prednisone How Is This Regimen Given? CVP is given every
Allergy Questionnaire. Name: Sex: M F. Contact Info: Home Phone:
Allergy & Asthma Centers of Fredericksburg & Fairfax 9010 Lorton Station Blvd #210 1300 Thornton Street, Suite 200 Lorton VA 22079 Fredericksburg, Virginia 22401 Tel:703-339-1660 Fax:703-372-5567 Tel:540-371-6810
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
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:
Yoon Nofsinger, M.D. Tampa ENT Associates, 3450 East Fletcher Avenue, Tampa, FL 33613 Phone (813) 972-3353, Fax (813) 978 3667
Yoon Nofsinger, M.D. Tampa ENT Associates, 3450 East Fletcher Avenue, Tampa, FL 33613 Phone (813) 972-3353, Fax (813) 978 3667 General Information: Allergies and Injection Therapy 1. General: You have
VAD Chemotherapy Regimen for Multiple Myeloma Information for Patients
VAD Chemotherapy Regimen for Multiple Myeloma Information for Patients The Regimen contains: V = vincristine (Oncovin ) A = Adriamycin (doxorubicin) D = Decadron (dexamethasone) How Is This Regimen Given?
Night frequency None 1 2 3 4 5 6 7 8 9 10. Not enough warning before needing to urinate. none mild moderate severe
{Patient Label} SYMPTOMS SURVEY: FREQUENCY: How many times do you urinate during the day and get up from sleep to urinate at night? Day frequency 3 4 5 6 7 8 9 10 11 12 13 14 15 More Night frequency None
A Caveat - Be Aware Of Quiz-Limitations
Hypothyroidism Progressive Treatment Quiz Think you may have a sluggish thyroid or what medicine calls hypothyroidism? Have you seen the doctors, but your blood tests keep coming back normal? Or did the
Allergies and Autoimmune Inner Ear Disease
Allergies and Autoimmune Inner Ear Disease Allergy is the term used to describe an over-reaction of the body to a substance that is normally harmless to most people. This substance is called an allergen,
CONSULTATION & CONSENT FORMS p. 1 of 5 C J HERBAL REMEDIES, INC. ********************************************************************************
CONSULTATION & CONSENT FORMS p. 1 of 5 ******************************************************************************** List your full name, age, sex, and today's date List your complete address List your
A ragweed pollen as a treatment for a ragweed allergy? It s called immunotherapy.
A ragweed pollen as a treatment for a ragweed allergy? It s called immunotherapy. RAGWITEK is a prescription medicine used for sublingual (under the tongue) immunotherapy to treat ragweed pollen allergies
Anaphylaxis: a severe, life threatening allergic reaction usually involving swelling, trouble breathing, and can progress to shock
Allergy is a condition in which the immune system causes sneezing, itching, rashes, and wheezing, or sometimes even life-threatening allergic reactions. The more you know about allergies, the better prepared
Surgery Health Survey
Surgery Health Survey Name: Social Security Number: Date of Birth: Please tell us which physician(s) we should contact regarding your visit: REFERRING PHYSICIAN Name: Address: PRIMARY CARE PHSYICIAN Name:
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
Patient Guide. Important information for patients starting therapy with LEMTRADA (alemtuzumab)
Patient Guide Important information for patients starting therapy with LEMTRADA (alemtuzumab) This medicinal product is subject to additional monitoring. This will allow quick identification of new safety
PODIATRIC ASSOCIATES OF NW OHIO, INC. PATIENT HISTORY INSURANCE INFORMATION
PODIATRIC ASSOCIATES OF NW OHIO, INC. DATE PATIENT HISTORY PATIENT S LAST NAME FIRST NAME MIDDLE SOCIAL SECURITY NUMBER ADDRESS STREET APT. NO. CITY STATE ZIP DATE OF BIRTH AGE SEX MARITAL STATUS HOME/CELL
Get Your Head In The Game. Matthew Voorman, MD Hutchinson Clinic March 21, 2016
Get Your Head In The Game Matthew Voorman, MD Hutchinson Clinic March 21, 2016 About Me Otolaryngology Head & Neck Surgery Geisinger Medical Center General Surgery University of California San Francisco
TCH: Docetaxel, Carboplatin and Trastuzumab
PATIENT EDUCATION patienteducation.osumc.edu TCH: Docetaxel, Carboplatin and Trastuzumab What is TCH? It is the short name for the drugs used for this chemotherapy treatment. The three drugs you will receive
Conjunctivitis - Pink Eye
Conjunctivitis - Pink Eye Introduction Conjunctivitis is often called pink eye. It causes inflammation of the thin, clear lining inside the eyelid and on the white of the eye. The inflammation gives the
Beach Family Doctors Medical Group
Beach Family Doctors Medical Group Welcome to our practice! Office Hours / After Hours 8:30am-5:00pm Monday through Friday; Closed for lunch; Closed all major holidays. For urgent medical issues after
NEW YORK STATE DEPARTMENT OF HEALTH BUREAU OF EMERGENCY MEDICAL SERVICES
NEW YORK STATE DEPARTMENT OF HEALTH BUREAU OF EMERGENCY MEDICAL SERVICES TRAINING PROGRAM OUTLINE FOR UNLICENSED OR UNCERTIFIED PERSONNEL TO ADMINISTER EPINEPHRINE BY AUTO-INJECTOR IN LIFE-THREATENING
Anaphylaxis. Exceptional healthcare, personally delivered
Anaphylaxis Exceptional healthcare, personally delivered 2 Introduction Anaphylaxis (also known as anaphylactic shock) is a severe, potentially fatal allergic reaction. Anaphylaxis is caused by your body
CHOP Chemotherapy Regimen for Lymphoma Information for Patients
CHOP Chemotherapy Regimen for Lymphoma Information for Patients The Regimen Contains: C: Cytoxan (cyclophosphamide) H: Adriamycin (hydroxy doxorubicin) O: vincristine (Oncovin ) P: Prednisone How Is This
PATIENT HEALTH QUESTIONNAIRE: Urology
PATIENT HEALTH QUESTIONNAIRE: Urology Patient Name: Sex: M F Last, First, Middle Initial Email: Date of Birth: \ \ Age: Social Sec #: - - Type of visit: Consultation requested by another Physician Self-referred
Allergy Shots and Allergy Drops for Adults and Children. A Review of the Research
Allergy Shots and Allergy Drops for Adults and Children A Review of the Research Is This Information Right for Me? This information may be helpful to you if: Your doctor* has said that you or your child
Board Certified Endocrinology, Diabetes & Metabolism Palm Harbor, FL 34684 Phone (727) 784-3366 FAX (727) 784-3527
Jerry Drucker, MD, FACE The Endocrine Center of Florida, LLC Board Certified Internal Medicine 34041 US Highway 19 North, Suite C Board Certified Endocrinology, Diabetes & Metabolism Palm Harbor, FL 34684
Subject ID: Subject Initials Date completed Interviewer. Person answering questions. 1 yes 2 no
COAST III Childhood Origins of ASThma Asthma Allergy Symptoms COAST 3 year visit Subject ID Subject ID: Subject Initials Date completed Interviewer Person answering questions 99. This form was completed
For the Patient: Dasatinib Other names: SPRYCEL
For the Patient: Dasatinib Other names: SPRYCEL Dasatinib (da sa' ti nib) is a drug that is used to treat many types of cancer. It is a tablet that you take by mouth. Tell your doctor if you have ever
Managing Menopause. Signs
Managing Menopause Menopause is a stage in a woman s life when the hormone levels of estrogen and progesterone decrease in the body. As hormone levels decrease, menstruation may be irregular and will eventually
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
CARY ORTHOPAEDIC SPORTS/SPINE SPECIALISTS/PERFORMANCE PHYSICAL THERAPY NEW PATIENT INFORMATION RECORD
CARY ORTHOPAEDIC SPORTS/SPINE SPECIALISTS/PERFORMANCE PHYSICAL THERAPY NEW PATIENT INFORMATION RECORD DATE PATIENT INFORMATION OUR DOCTOR CHART NO. LAST NAME FIRST NAME MIDDLE INITIAL MAIDEN NAME Are you
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
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
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
412 Holistic Health, LLC Maura Schuster, L.OM 412.841.2065 Practitioner of Oriental Medicine NEW PATIENT INTAKE
412 Holistic Health, LLC Maura Schuster, L.OM 412.841.2065 Practitioner of Oriental Medicine NEW PATIENT INTAKE PATIENT INFORMATION Date Name Address City State Zip Age Birthdate Occupation Company name
traditional medicine for modern times tm Laura Gabbé, LAc, MS Acupuncture & Herbs
traditional medicine for modern times tm Laura Gabbé, LAc, MS Acupuncture & Herbs FIRST NAME LAST NAME ADDRESS CITY STATE ZIP HOME PHONE OTHER PHONE EMAIL OCCUPATION INSURANCE CO. INSURER S NAME SELF SPOUSE
Patient Information Form Pain Management Center at Phoebe
Patient Information Form Pain Management Center at Phoebe Please complete the following form, so that we may facilitate your visit Occupation: or (circle) Retired, Disabled Homemaker, Full time student
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:
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
Cyclosporine (Neoral)
Cyclosporine (Neoral) How does it work? Cyclosporine is used to lower the body s immune system. Your immune system, which normally helps to protect your body from infection and disease, is out of order.
Chemotherapy Side Effects Worksheet
Page 1 of 6 Chemotherapy Side Effects Worksheet Medicines or drugs that destroy cancer cells are called cancer chemotherapy. It is sometimes the first choice for treating many cancers. Chemotherapy differs
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
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
Disclosure Form. Memberships: National Certification Commission for Acupuncture and Oriental Medicine (Dipl. Acup.)
Consent Form By signing below, I do hereby voluntarily consent to be treated with acupuncture and/or substances from the Oriental materia medica Matt Hillman, L.Ac. I understand that acupuncturists practicing
THE ALLERGIGROUP NEW PATIENT HISTORY PATIENT DATE. Recurrent Infections
Roberto Garcia M.D., P.A. Asthma, Allergy and Immunology Children and Adults Patient Identification ( ) Mr. ( ) Mrs. ( ) Ms. ( ) Male ( ) Female LAST NAME FIRST M.I. AGE D.O.B. Social Security # Address
PATIENT INFORMED CONSENT FOR APPETITE SUPPRESSANTS
PATIENT INFORMED CONSENT FOR APPETITE SUPPRESSANTS I, authorize Performance Weight Loss to assist me in my weight loss reduction efforts. I understand that my program consists of a balanced deficit diet,
MEDICATION GUIDE. Bupropion Hydrochloride (bue-proe-pee-on HYE-droe-KLOR-ide) Extended-Release Tablets, USP (SR)
MEDICATION GUIDE Bupropion Hydrochloride (bue-proe-pee-on HYE-droe-KLOR-ide) Extended-Release Tablets, USP (SR) Read this Medication Guide carefully before you start taking bupropion hydrochloride extendedrelease
MEDICINES TO CONTINUE TAKING PRIOR TO ALLERGY TESTING
5929 S. Fashion Point Dr. Suite 101, South Ogden, UT 84403 (801) 476-0052 fax (801) 476-0064 The physicians and staff of Intermountain Allergy & Asthma welcome you to our practice! The following information
MEDICATION GUIDE WELLBUTRIN (WELL byu-trin) (bupropion hydrochloride) Tablets
MEDICATION GUIDE WELLBUTRIN (WELL byu-trin) (bupropion hydrochloride) Tablets Read this Medication Guide carefully before you start using WELLBUTRIN and each time you get a refill. There may be new information.
All product claims should be truthful, not misleading, and should be backed by scientific evidence.
SHARING YOUNG LIVING the Right Way The U.S. and most other countries have regulations in place designed to protect consumers. Many of these specifically regulate how natural wellness companies like Young
Interventional Spine Care New Patient History and Intake Form
Interventional Spine Care New Patient Introduction You have been referred to Dr. Hamburger/Dr. Olson. Our focus is the evaluation and management of low back pain, and other disorders of the spine. Our
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:
1. LAMICTAL may cause a serious skin rash that may cause you to be hospitalized or even cause death.
MEDICATION GUIDE LAMICTAL (la-mik-tal) (lamotrigine) tablets LAMICTAL (lamotrigine) chewable dispersible tablets LAMICTAL ODT (lamotrigine) orally disintegrating tablets What is the most important information
FDA-Approved Patient Labeling IMPLANON (etonogestrel implant) Subdermal Use
FDA-Approved Patient Labeling IMPLANON (etonogestrel implant) Subdermal Use IMPLANON does not protect against HIV infection (the virus that causes AIDS) or other sexually transmitted diseases. Read this
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 ( )
Swine Flu and Common Infections to Prepare For. Rochester Recreation Club for the Deaf October 15, 2009
Swine Flu and Common Infections to Prepare For Rochester Recreation Club for the Deaf October 15, 2009 Supporters Deaf Health Community Committee Members Julia Aggas Cathie Armstrong Michael McKee Mistie
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
TC: Docetaxel and Cyclophosphamide
PATIENT EDUCATION patienteducation.osumc.edu What is TC? It is the short name for the drugs used for this chemotherapy treatment. The two drugs you will receive during this treatment are Docetaxel (Taxotere
EMPLOYEE HEALTH SERVICE 600 Highland Avenue, Madison, WI 53792 Mail Code 6715 (608) 263 7535 FAX: (608) 262 7284 HEALTH ASSESSMENT
EMPLOYEE HEALTH SERVICE 600 Highland Avenue, Madison, WI 53792 Mail Code 6715 (608) 263 7535 FAX: (608) 262 7284 HEALTH ASSESSMENT FULL NAME DATE (LAST) (FIRST) (MIDDLE) HOME ADDRESS (STREET) (CITY) (STATE)
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:
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
Patient Medical History Form
Patient Medical History Form Patient Name: To help the doctor serve you better, please complete the information below. Thank you! Allergies: No known Allergies (If yes, please list all Drug, Food, and
MEDICATION GUIDE. PROTOPIC [pro-top-ik] (tacrolimus) Ointment 0.03% Ointment 0.1%
![MEDICATION GUIDE. PROTOPIC [pro-top-ik] (tacrolimus) Ointment 0.03% Ointment 0.1%](/thumbs/27/10084771.jpg "MEDICATION GUIDE. PROTOPIC [pro-top-ik] (tacrolimus) Ointment 0.03% Ointment 0.1%")
MEDICATION GUIDE PROTOPIC [pro-top-ik] (tacrolimus) Ointment 0.03% Ointment 0.1% Read the Medication Guide every time you or a family member gets PROTOPIC Ointment. There may be new information. This Medication
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:
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
Controlling Pain Part 2: Types of Pain Medicines for Your Prostate Cancer
Controlling Pain Part 2: Types of Pain Medicines for Your Prostate Cancer The following information is based on the general experiences of many prostate cancer patients. Your experience may be different.
Otis R. Washington, D.D.S., M.S., P.A. Diplomate of the American Board of Periodontology
Otis R. Washington, D.D.S., M.S., P.A. Diplomate of the American Board of Periodontology 2310 Myron Drive Raleigh, North Carolina 27607 P: (919) 782-9536 F: (855) 787-8025 Name: SSN: Date of Birth (mmddyy):
PAIN MANAGEMENT During Your Hospital Stay
PAIN MANAGEMENT During Your Hospital Stay TABLE OF CONTENTS Understanding Pain...2 Pain Assessment...2 Describing Your Pain...5 Pain Treatment...5 Comfort Measures...6 Medication...7 Specialty Procedures...8
SLEEP DISORDER ADULT QUESTIONNAIRE
SLEEP DISORDER ADULT QUESTIONNAIRE Name: Date: Date of Birth (month/day/year): / / Gender: ο Male ο Female Marital Status: ο Never Married ο Married ο Divorced ο Widowed Home Address: City: Zip: Daytime
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
Please fill out forms, sign where needed and bring with you to your first visit. If you have any questions please call the office at 212-751-8300.
Welcome to Manhattan Sports Medicine and the office of Dr. Kyle Worell. Before we get started please see all forms below: Personal History (Intake) Informed Consent Payments HIPPA Please fill out forms,
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
Paclitaxel and Carboplatin
PATIENT EDUCATION patienteducation.osumc.edu What is Paclitaxel (pak-li-tax-el) and how does it work? Paclitaxel is a chemotherapy drug known as an anti-microtubule inhibitor. Another name for this drug
Allergies: ENT and Allergy Center of Missouri YOUR GUIDE TO TESTING AND TREATMENT. University of Missouri Health Care
Allergies: YOUR GUIDE TO TESTING AND TREATMENT ENT and Allergy Center of Missouri University of Missouri Health Care 812 N. Keene St., Columbia, MO 65201 (573) 817-3000 www.muhealth.org WHAT CAUSES ALLERGIES
RETINA CARE CENTER, P.C. PATIENT INFORMATION
RETINA CARE CENTER, P.C. JONATHAN M. BAROFSKY, M.D., F.A.C.S. Parkway Seventy Plaza 1255 Route 70, Suite 31N Lakewood, New Jersey 08701 PHONE (732)905 0004 FAX (732)905 3868 PATIENT INFORMATION Welcome
PATIENT DEMOGRAPHICS:
PATIENT DEMOGRAPHICS: Last Name: First: MI: Address: City: State: Zip: Please check off the phone numbers you would like us to call regarding appointment conformations. Home: Cell: May we leave a message?
Cutting Edge Eye Care
Cutting Edge Eye Care The Optos Daytona provides an unequaled 200 degree view of your retina in a single image. This view gives our doctors the opportunity to identify and follow peripheral retinal pathology
THE 7:16 WAS ON TIME BUT MY LEGS WERE BEHIND SCHEDULE THAT S WHEN I ASKED FOR THE WALKING PILL
THE 7:16 WAS ON TIME BUT MY LEGS WERE BEHIND SCHEDULE THAT S WHEN I ASKED FOR THE WALKING PILL See page 12 for FREE* TRIAL OFFER *Limitations and restrictions apply. Actor portrayal AMPYRA (dalfampridine)
Allergic rhinitis means allergies in the nose. Hay fever is allergies that occur during a certain season of the year.
What is allergic rhinitis? Allergic rhinitis means allergies in the nose. Hay fever is allergies that occur during a certain season of the year. What are the symptoms? nasal congestion sneezing tearing
MEDICATION GUIDE KOMBIGLYZE XR (kom-be-glyze X-R) (saxagliptin and metformin HCl extended-release) tablets
MEDICATION GUIDE KOMBIGLYZE XR (kom-be-glyze X-R) (saxagliptin and metformin HCl extended-release) tablets Read this Medication Guide carefully before you start taking KOMBIGLYZE XR and each time you get