Calgary Drop-In & Rehab Centre
|
|
|
- Jocelyn Richard
- 8 years ago
- Views:
Transcription
1 Calgary Drop-In & Rehab Centre A Picture of the Health of a Homeless Individual by Dr. Isabel Ries Ferrari Ed.D Kim Brown BA John Rowland P.Eng Larissa Kennedy BA
2 The Calgary Drop-In & Rehab Centre (Calgary Drop-In) provides services of food, shelter, and clothing, counselling and basic medical attention to all those in need. In operation since 1961, the Calgary Drop-In & Rehab Centre now sleeps 1100 nightly, and provides meals to 3500 people daily. Providing health services to the complex medical problems faced by the homeless are one of the challenges providers struggle with. This presentation is an examination of the breakdown in the continuum of care. ABSTRACT Objective: A data collection study was completed to meet the following objectives: to obtain a snapshot picture of the current health of Drop-In clients. to determine which medical services are used by clients to examine gaps in services and providers The Calgary Drop-In & Rehab Centre, an emergency shelter located in Calgary s downtown core, has approximately individuals using the shelters services on any given night. A noticeable trend has emerged, as the numbers of shelter users have grown; clients have increasingly more complex medical conditions. As a result of these complexities, there is a need to provide appropriate, integrated care. A study was completed in-house asking clients about the length of time they have been homeless; their impressions of their health; where they seek medical services; the types of medical conditions they currently live with; the types of medication they have been prescribed and are currently taking; and how they pay for their medications. A sample of one hundred fifty-one (151) clients were surveyed, approximately 15% of the CDIRC s sheltered population. METHODOLOGY Procedure Method: Self Reporting Questionnaire of 151 Drop-In clients; about 15% of the population. length of time homeless impression of health where they seek medical attention medical conditions they live with types of medication prescribed how they pay for prescriptions
3 Demographics of population surveyed Gender: 88% male / 12% female Location of demographic surveyed Intox: 75% male / 25% female Emergency: 91% male / 9% female Transitional: 87% male / 13% female Types of sleeping services offered at the Calgary Drop-In & Rehab Centre: 1. Intox beds: are for individuals under the influence of either drugs or alcohol. 2. Emergency beds: are for sober individuals on a first come, first serve basis. 3. Transitional beds: semi-permanent housing to facilitate the move from shelter to independent living.
4 Intox Shelter Clients - Age Range % % 65+ 5% % % % Intox Shelter Clients - Length of Time living on the streets or in a shelter. 45.0% 40.0% 35.0% 30.0% 25.0% 20.0% 15.0% 10.0% 5.0% 0.0% < 1 month 1-6 months 7-12 months 1-3 years 4-6 years 7-10 years > 10 years
5 Intox Shelter Clients - Right now, how would you rate your overall health? 45.0% 40.0% 35.0% 30.0% 25.0% 20.0% 15.0% 10.0% 5.0% 0.0% very poor poor average above average good very good Intox Shelter Clients - Where do you usually go for medical treatment? 90.0% 80.0% 70.0% Primary health provider Secondary health provider 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% CUPS 8th & 8th Alex Emerg Family Dr. Walk-in None
6 Intox Shelter Clients - Please list any medical conditions or concerns? 50.0% 45.0% 40.0% 35.0% 30.0% 25.0% 20.0% 15.0% 10.0% 5.0% 0.0% Total of 20 Clients Interviewed Concerns Reported by clients 12 - Alcoholism 8 - feet and leg problems 4 - hypertention 3 - siezures 3 - broken bones 3 - heart condition 2 - Athsma 2 - larengitis 2 - depression 2 - diabetes 2 - drug addiction 2 - thyroid 2 - hep-c 1- arthritis 1 - bipolar 1 - cyatic nerve 1 - manic-depressive 1 - blind in one eye 1 - nerve damage 1 - steel plate in jaw 1 - exema 1 d l No concerns / conditions 1-2 concern / conditions 3-5 concerns / conditions >5 concerns / conditions Intox Shelter Clients - Have you ever been prescribed ongoing medications? Are you taking the above regularly? 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% Medications reported 4 - dilantin advair venolin centrum fluoxetine norvasc tylenol 3 blood pressure pill eltroxin paxil ibupruten pms glyberide concerta pms-gabapentin vasotec plendil premarin? lotensin altace hydrochlorthiazide asa metformin wellbutrin lithium Reasons given 2 - Cost 1- Stolen 1 - Do not work 1 - Do not bother Yes No Taking Not taking
7 Emergency Shelter Beds - Age Range 65+ 2% % % % % % Emergency Shelter Clients - Length of Time living on the streets or in a shelter. 45% 35% 25% 15% 5% -5% < 1 month 1-6 months 7-12 months 1-3 years 4-6 years 7-10 years > 10 years
8 Emergency Shelter Clients - Right now, how would you rate your overall health? 45% 35% 25% 15% 5% -5% very poor poor average above average good very good Emergency Shelter Clients - Where do you usually go for medical treatment? 90% 80% 70% 60% Primary health provider Secondary health provider 50% 40% 30% 20% 10% 0% CUPS 8th & 8th Alex Emerg Family Dr. Walk-in None
9 Emergency Shelter Clients - Please list any medical conditions or concerns? 50% Total of 66 Clients interviewed - 15% of population Number of Respondents 45% 40% 35% 30% 25% 20% 15% Concerns Reported by clients 7 - feet and leg problems 6 - dental 6 - Flu / cold 3 - Pneumonia 3 - broken bones 2 - heart condition 1 - seizures 1 - thyroid 1 - hep-c 1- arthritis 1 - Stress 1 - Bruising 2 - Sleeping Disorder 1 - Anxiety 1 Bl d Cl t 1 -Eye Infection 2 - sclerosis 1 - Breathing & Lung 1 - Cancer 2 - Dizziness 1 - Ulcers 1 - Gluten Intolerance 1 - Gout 1- Swollen Hip 1 - Lacerations 1 - Bronchitis 10% 5% 0% No concerns / conditions 1-2 concern / conditions 3-5 concerns / conditions >5 concerns / conditions Emergency Shelter Clients - Have you ever been prescribed ongoing medications? Are you taking the above regularly? 60% 50% 40% Medications reported Reasons given 4 - Cost 2 - Cut Off 1 - Only when required 1 - Does not work 1 - Overdose 1 - Finished Prescription 1 N 30% 20% 10% 0% advair 8 - puffers-flovent ventlin (salmutamol) inhalers puffer - combivent lithium paxil arthrotec antidepressants 3 - effexor zoloft neproxen nitro apo doxycycline 3 - do not know betamethasone celebrex ibuprofen ferrous gluconate wellbutrin metoprolol water pill tylenol 4 tylenol 3 coumadin seroquel rhoxal-bisoprolol spironolactone fosinopril apo-cal? flexeril apo furosemide steroids (lungs) oxycodone glucosamine folic acid flomax ensure arthrotec Yes No Taking Not Taking
10 Transitional Shelter Clients - Age Range 65+ 0% % % % % % Number of Respondents Transitional Shelter Clients - Length of Time living on the streets or in a shelter. Total of 53 Clients interviewed - 15% of population < 1 month 1-6 months 7-12 months 1-3 years 4-6 years 7-10 years > 10 years
11 Number of respondents Transitional Shelter Clients - Right now, how would you rate your overall health? Total of 53 Clients interviewed - 15% of population very poor poor average above average good very good Transitional Shelter Clients - Where do you usually go for medical treatment? Primary health provider Secondary health provider Number of Respondents CUPS 8th & 8th Alex Emerg Family Dr. Walk-in None
12 Transitional Shelter Clients - Please list any conditions or concerns? 50.00% 45.00% 40.00% 35.00% Concerns Reported by clients 30.00% 25.00% 20.00% 15.00% 10.00% 5.00% 10 - Alcoholism 1 - Drug Addiction 9 - Depression 4 - feet and leg problems 9 - dental 2 - Flu / cold 1 - Pneumonia 1 - heart condition 1 - thyroid 7 - hep-c 7- arthritis 2 - Stress 3 - Anxiety 5 - Bad Back 2 - Cancer 1 - Bronchitis 1 - Numbness in hand 1 - Ringing in ear 1 - Obesity 1 - Bursitis 1 - Calcium in feet 1 - Ovarian cyst 2 - Amputee 7 - Hypertension 6 - Asthma 1 - HIV 1 - Tendonitis 1 - Social Adjustment 1 - borderline personality 1 - Chronic fatigue 1 - Fibromyalgia 2 - Hypoglycemia 1 - Brain aneurism 2 - Paranoid schizophrenia 1 - ADHD 2 - Epilepsy 1 - Rashes 3 - Hernia 1 - Sciatic nerve 1 psorisis 0.00% No concerns / conditions 1-2 concern / conditions 3-5 concerns / conditions >5 concerns / conditions Emergency Shelter Clients - Have you ever been prescribed ongoing medications? Are you taking the above regularly? 60% 50% 40% Medications reported Reasons given 4 - Cost 2 - Cut Off 1 - Only when required 1 - Does not work 1 - Overdose 1 - Finished Prescription 1 N 30% 20% 10% 0% advair 8 - puffers-flovent ventlin (salmutamol) inhalers puffer - combivent lithium paxil arthrotec antidepressants 3 - effexor zoloft neproxen nitro apo doxycycline 3 - do not know betamethasone celebrex ibuprofen ferrous gluconate wellbutrin metoprolol water pill tylenol 4 tylenol 3 coumadin seroquel rhoxal-bisoprolol spironolactone fosinopril apo-cal? flexeril apo furosemide steroids (lungs) oxycodone glucosamine folic acid flomax ensure arthrotec Yes No Taking Not Taking
13 Observations Female respondents perceived their health as very poor to average as compared to the male respondents whose perceptions ranged from very poor to very good. Respondents living in Intox and Transitional housing were older and longer on the streets than those living in emergency shelter beds. Respondents living in emergency shelter beds have a perceived health from poor to very good, however the longer the respondent lived on the streets a decline of perceived health was reported. No matter where a respondent resided in the shelter system, they reported their health as Average, even if they reported more than 2 medical conditions or concerns. The primary service provider was 8th &8th Medical Centre, followed by CUPS. Almost 60% of respondents stated that they will not go to another medical service provider as a secondary service provider. 71% of the respondents did not have a family doctor Majority of respondents paid for their medications either by cash or through Social Services. Our Conclusions Homelessness affects the health and well-being of an individual. The longer they are on the streets, there appears to be an inconsistency between the observed health of the individual and the individual s personal perception of their own level of health As one s housing becomes more stable, their perceptions of their health become more realistic and their overall health and well-being appear to improve. There is a need for a continuum of care for the homeless population. An integrated care model would benefit this population s diverse medical needs including addictions and mental health. Discussion Survival is this population s primary struggle. The medical needs of the homeless do not meet the criteria of any one medical service provider, therefore an integrated care model would benefit this population s diverse medical needs including addictions and mental health. Most homeless people suffer from one or more chronic conditions, yet our delivery systems are focused on the episodic treatment of chief complaints at a given moment in time. Readily accessible, consistent, and continuous care from a known, trusted clinician is not always available for many people experience homelessness. For an agency that offers services to more than 1100 individuals a night, an on-site medical clinic would be of great benefit to meet their medical needs. * Survey and data all conducted November 2005 by Calgary Drop-In Staff.
Providence Alliance for Catholic Teachers (PACT)
Providence Alliance for Catholic Teachers (PACT) Health and Wellness History Please place this form in a separate sealed envelope, marked with your name and Health and Wellness History. Submit to PACT
Cancellation/No Show Policy
Cancellation/No Show Policy If you are unable to keep your scheduled appointment we require a 24 hour advance notice. Failure to provide this notice will result in a $50.00 cancellation/no show fee. You
How To Fill Out A Health Declaration
The English translation has no legal force and is provided to the customer for convenience only. The Dutch health declaration should be filled in. Health declaration for occupational disability insurance
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
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
MVA Accident Questionnaire
MVA Accident Questionnaire Name Date Date of Accident Time of Accident Road conditions at time of accident Were you the driver? Were you the passenger? Where were you seated in the vehicle? FRONT BACK
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
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
Patient Intake Form. Patient Information. How did you find out about our office?
Atlanta Injury and Wellness Center 2740 Greenbriar Parkway Suite A 3 Atlanta, GA 30331 404 629 9999 Patient Intake Form Welcome to our office of chiropractic. Thank you for taking a moment to fill in our
SUMMARY OF FINDINGS: OMF 2015 MEDICAL NEEDS ASSESSMENT
SUMMARY OF FINDINGS: OMF 2015 MEDICAL NEEDS ASSESSMENT DEMOGRAPHICS Total surveys completed: 341 62 % Eastsound area 13 % Deer Harbor area 16 % Olga area 9 % Orcas Ferry area Age 2 % 25 34 8 % 35 44 13
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
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
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.
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
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
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.
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.)
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
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
% of time working at heights % What is the average height you work at?
Relevant for Income Protection cases only: 18 Do any of the following form an essential part of your work? a manual work YES NO % of time at Manual work % b Driving YES NO % of time Driving % Average weekly
6. Do you have an Advance Directive or Living Will? Yes No These are written statements about how you want to be treated if you get very sick.
Adult Health History Name: First Last Name you like to be called: Today s Date: Date of Birth: Male Female Transgender Male to Female Transgender Female to Male Other Filling out this form Answering these
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
Step 1: Complete the attached Health Appraisal and Medical History Questionnaire, Goal Inventory, and Liability Waiver.
Please use the contact information below for questions or concerns. Abraham Lincoln High School Name: Eric Nicholson Email: Eric_Nicholson@dpsk12.org Phone: 7204235043 Bruce Randolph School Name: Greg
PATIENT INFORMATION / / OTHER CONTACT NUMERS: (CIRCLE ONE) CELL, HOME OR OTHER. ENTER NUMBER BELOW. ( ) EMPLOYER ( )
PATIENT INFORMATION PATIENT S LEGAL NAME DATE OF BIRTH AGE DATE / / / / HEIGHT AND WEIGHT SEX REASON FOR VISIT: MARITAL STATUS FT IN LBS MALE FEMALE S M D W ADDRESS CITY STATE ZIP CODE THE BEST NUMBER
NEW PATIENT HISTORY Mark L. Prasarn, M.D.
NEW PATIENT HISTORY Mark L. Prasarn, M.D. Date: Name: Age: Height: Weight: Pharmacy: Phar. Phone#: Primary Care M.D. Referring M.D.: What is your Chief Complaint? What makes the pain better? Neck Pain
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
CHIEF COMPLAINT: Please number your symptoms (1 is the most severe) that you have developed since the accident.
VANCE CHIROPRACTIC PERSONAL INJURY QUESTIONAIRE (PLEASE BE VERY SPECIFIC WITH YOUR ANSWERS THANK YOU!) Last Name First Name Middle Home Phone Work Phone Street Address and Number Mailing Address if Different
PATIENT INFORMATION: PATIENT CONTACT PHONE NUMBERS: PHYSICIAN INFORMATION: HEALTH INSURANCE INFORMATION:
PATIENT INFORMATION: TODAY S DATE: HOW DID YOU HEAR ABOUT US?: LAST NAME: FIRST NAME: STREET CITY: STATE: ZIP: EMAIL MARTIAL STATUS: SINGLE MARRIED DIVORCED WIDOWED SEPARATED BIRTHDATE: AGE: SEX: MALE
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
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:
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:
Liver Disease & Hepatitis Program Providers: Brian McMahon, MD, Steve Livingston, MD, Lisa Townshend, ANP. Primary Care Provider:
Liver Disease & Hepatitis Program Providers: Brian McMahon, MD, Steve Livingston, MD, Lisa Townshend, ANP Primary Care Provider: If you are considering hepatitis C treatment, please read this treatment
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:
EZ REHAB SOLUTIONS: Patient Intake Information
EZ REHAB SOLUTIONS: Patient Intake Information PATIENT INFORMATION EMAIL ADDRESS: First Name: Last Name: Middle Initial: : / / Address: City: State: Zip: Birth date: / / Age: Male Female S.S. #: - - Home
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.
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
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
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
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,
34 th Judicial District Substance Abuse Study Guide
34 th Judicial District Substance Abuse Study Guide What is Drug Addiction? 2 It is characterized by intense and, at times, uncontrollable drug craving, along with compulsive drug seeking and use that
Adult Information Form Page 1
Adult Information Form Page 1 Client Name: Age: DOB: Date: Address: City: State: Zip: Home Phone: ( ) OK to leave message? Yes No Work Phone: ( ) OK to leave message? Yes No Current Employer (or school
Welcome to Chirosports Coogee
PAGE 1 OF 6 Welcome to Chirosports Coogee At Chirosports our goal is to optimise your health and increase your quality of life. Chiropractic is an approach to health and wellbeing that assists the body
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
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.
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)
Medical History Questionnaire
Medical History Questionnaire Name: Date: Allergies (including latex): List all medications that you are currently taking, either prescription or non- prescription. Please specify dosage and length of
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:
Pharmacology 260 Online Course Schedule Spring 2012
Pharmacology 260 Online Course Spring 2012 The topics listed below do not necessarily correspond to a 1 - hour lecture period. You should cover the topics for each week at some time during that week. Readings
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
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
Medications for chronic pain
Medications for chronic pain When it comes to treating chronic pain with medications, there are many to choose from. Different types of pain medications are used for different pain conditions. You may
Patient Case Information (Please Fill Out Forms Completely) (IF PATIENT IS UNDER 18 YEARS OF AGE LEGAL GUARDIAN MUST SIGN ALL PAPERWORK)
Patient Name: Patient Case Information (Please Fill Out Forms Completely) (IF PATIENT IS UNDER 18 YEARS OF AGE LEGAL GUARDIAN MUST SIGN ALL PAPERWORK) (Last), (First) (Middle Initial) Address: City: State:
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
Patient Information. Name: Social Security Number: Birth date: Email: Address: Phone #: House: Cell: Work: Primary Care Physician: Address:
Patient Information Name: Social Security Number: Birth date: Age: Email: Address: Phone #: House: Cell: Work: Primary Care Physician: Phone #: Date Last Visit: Address: Emergency Contact: Emergency Phone
How To Quit Smoking
The American College of Obstetricians and Gynecologists f AQ FREQUENTLY ASKED QUESTIONS FAQ065 WOMEN S HEALTH It s Time to Quit Smoking What are the dangers of smoking? How does smoking affect the body?
ORANGE COUNTY EYE INSTITUTE
ORANGE COUNTY EYE INSTITUTE *Note: It is the patient s responsibility to file insurance claims if we are not contracted with your insurance company. *Note: Be aware that most medical insurance plans do
cymbalta and cold meds muscle pain cymbalta cymbalta samples cymbalta smell cost of cymbalta cymbalta mini mal seisures, is cymbalta a stimulant,
cymbalta and cold meds muscle pain cymbalta cymbalta samples cymbalta smell cost of cymbalta cymbalta mini mal seisures, is cymbalta a stimulant, cymbalta addiction and withdrawal side effects. how to
Depression and Mental Health:
Depression and Mental Health: A Psychiatrist s Perspective Peter M. Lake, MD Medical Director Rogers Memorial Hospital Oconomowoc Depression The Intersection of Hope, Medicine and Research Marquette University
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
FIREFIGHTER I ACADEMY APPLICATION & CHECKLIST
Department of Public Safety - Technology 11400 Greenstone Avenue Santa Fe Springs California 90670 Tracy Rickman, Academy Coordinator (562) 941-4082 Class FIREFIGHTER I ACADEMY APPLICATION & CHECKLIST
WELCOME Thank you for taking the time to fill out this form. It will enable us to provide quality, personalized dental care for you.
HIRSHFIELD DENTAL CARE 50 NORTH ST. MEDFIELD, MA 02052 Today s date WELCOME Thank you for taking the time to fill out this form. It will enable us to provide quality, personalized dental care for you.
DEPRESSION Depression Assessment PHQ-9 Screening tool Depression treatment Treatment flow chart Medications Patient Resource
E-Resource March, 2015 DEPRESSION Depression Assessment PHQ-9 Screening tool Depression treatment Treatment flow chart Medications Patient Resource Depression affects approximately 20% of the general population
NEW PATIENTS' INFORMATION SHEET
NEW PATIENTS' INFORMATION SHEET Please print clearly. Please complete all information so that your claim can be processed quickly and efficiently. Thank you! PATIENT INFORMATION (First) (MI) (Last) Name
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
Advanced Rehab Solutions 609 Morris Avenue Springfield, NJ 07081
Advanced Rehab Solutions 609 Morris Avenue Springfield, NJ 07081 PLEASE COMPLETE ALL OF THE INFORMATION. REFERRED BY: LAST NAME MIDDLE FIRST STREET ADDRESS CITY STATE ZIP CODE HOME PHONE ( ) - WORK ( )
Medicines for Treating Depression. A Review of the Research for Adults
Medicines for Treating Depression A Review of the Research for Adults Is This Information Right for Me? Yes, if: A doctor or other health care professional has told you that you have depression. Your doctor
Please find attached an application form, please read the following information before completing the form.
Page: 1 of 12 STEAM MILL BUSINESS CENTRE STEAM MILL STREET CHESTER CH3 5AN TEL: 01244 354700 FAX: 01244 354720 E-MAIL: info@anchorgroup.eu WEB SITE: http://www.anchorgroup.eu Dear Candidate, Re: Job Application
1. NAME 2. SOCIAL SECURITY NUMBER # 4. PRESENT OCCUPATION 5. PLANT 6. ADDRESS 8. TELEPHONE NUMBER 9. INTERVIEWER
ASBESTOS INITIAL MEDICAL QUESTIONNAIRE 1. NAME 2. SOCIAL SECURITY NUMBER # 3. CLOCK NUMBER 4. PRESENT OCCUPATION 5. PLANT 6. ADDRESS 7. (Zip Code) 8. TELEPHONE NUMBER 9. INTERVIEWER 10. DATE 11. Date of
Amino Acid Therapy to Restore Neurotransmitter Function
Amino Acid Therapy to Restore Neurotransmitter Function Alvin Stein, MD Neurotransmitters are chemicals manufactured by our bodies that allow our nervous system to function properly. When the body requires
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
Fall Registration Checklist
Fall Registration Checklist Please use the following form to check off necessary paperwork needed to get ready for the school year 1. Please complete the following paperwork and items Medical Emergency
KEY PERSON INSURANCE (Accident & Sickness) PROPOSAL FORM
KEY PERSON INSURANCE (Accident & Sickness) PROPOSAL FORM E.U. DISCLOSURE CLAUSE (UK) tice to the Proposer/Insured The Parties are free to choose the law applicable to this insurance Contract. Unless specifically
Health Information Form for Adults
A. IDENTIFICATION B. EMERGENCY CONTACTS Name (Last) (First) (Middle) Maiden Name Primary Alternate In Case of Emergency, Notify: Primary Contact Name (Last) (First) (Middle) Relationship Home Work Home
UNM Pain Center: Addressing New Mexico s Public Health Crises of Pain, Addiction, and Unintentional Opioid Overdose Deaths
UNM Pain Center: Addressing New Mexico s Public Health Crises of Pain, Addiction, and Unintentional Opioid Overdose Deaths Joanna G Katzman, M.D., M.S.P.H Director, UNM Pain Center Associate Professor,
Patient Registration Form
PATIENT INFORMATION Patient Registration Form (Please Print) Dr. Miss Mr. Mrs. Ms. Sir Jr. Sr. Patient s Name (Last) (First) (MI) Previous Name Mailing Address City, State, ZIP (+4) Physical Address City,
Last Name First Name Middle Initial Address Apt # City State Zip Home Phone ( ) Mobile Phone ( ) Work Phone ( )
Patient Registration A. P A T I E N T Please Print Legibly on Form Account # Address Apt # City State Zip DOB (mm/dd/yy) Gender Male Female SSN # Preferred Contact Method: Home Ph Mobile Ph Text E-mail
Medicare Health Risk Assessment Questionnaire
Medicare Health Risk Assessment Questionnaire Instructions: Please complete and return it in the self-addressed stamped envelope provided. If you have questions or need help completing the questionnaire,
Work Injury Information Continued
Welcomes You Full Name: Today s Date: DOB: M / F Social Security #: DL# Address: City: State: Zip Code: Home # : Cell #: Occupation: Employer: Employer Address: Employer Phone: Employer Fax: Emergency
(928) 854-4307 MEDICAL HISTORY. Weight: _ Shoe size: _
2302 N. Stockton Hill Rd Ste. G 1731 Mesquite Ave Ste 4 1200 Mohave Rd MEDICAL HISTORY Weight: Shoe size: ~~~~~~~~~~~~~~~~~~~~~~~~~~PLEASECIRCLE: RIGHT or LE~ Is your problem due to an accident? YES or
For the Patient: GDP Other names: LYGDP
1 For the Patient: GDP Other names: LYGDP G D P Gemcitabine Dexamethasone (taken by mouth) CISPlatin Uses: GDP is a drug treatment given for Non-Hodgkins and Hodgkin Lymphoma with the expectation of destroying
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
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
OSHA INITIAL ASBESTOS MEDICAL QUESTIONNAIRE
OSHA INITIAL ASBESTOS MEDICAL QUESTIONNAIRE 1. NAME 2. SOCIAL SECURITY NUMBER # 3. CLOCK NUMBER FULL TIME PART TIME 4. PRESENT OCCUPATION 5. PLANT / Department 6. ADDRESS (City, ST Zip) 8. TELEPHONE NUMBER
Venous Thrombosis and Pulmonary Embolism Treatment with Rivaroxaban
Venous Thrombosis and Pulmonary Embolism Treatment with Rivaroxaban Information for patients and families Read this booklet to learn: about venous thrombosis and pulmonary embolism how the medicine Rivaroxaban
WHAT IT MEANS TO BE A TEAM LEADER. Presented by: Arthur Berger, Ed.D Director of Behavioral Health
WHAT IT MEANS TO BE A TEAM LEADER Presented by: Arthur Berger, Ed.D Director of Behavioral Health Overview of Urban Health Plan (UHP) Federally Qualified Community Health Center JCAHO accredited Located
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
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
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
Dr. David Y. Liao, D.O. Orthopedic Center, LLC. Release of Information
Release of Information The purpose of this form is to alert our office as to those family members and/or friends who may be scheduling or canceling appointments on your behalf and/or will need to have
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
PATIENT INFORMATION SHEET. Last Name: First Name: MI: Home Address: Apt# City: State: Zip Code: Home Phone #: Cell Phone #:
PATIENT INFORMATION SHEET PATIENT Last Name: First Name: MI: Gender: M F Date of Birth: / / SS# Home Address: Apt# City: State: Zip Code: Home Phone #: Cell Phone #: Employer Name: Work Phone #: Email
NORTHERN EDGE PHYSICAL THERAPY
REGISTRATION PAPERWORK CHECKLIST In order to make registration simple and quick, please use this checklist to make sure you have provided all necessary information and signatures. The process, including
Alcohol and drug abuse
Alcohol and drug abuse This chapter explores how alcohol abuse affects our families, relationships, and communities, as well as the health risks associated with drug and alcohol abuse. 1. Alcohol abuse
Personal Training Health Screening Questionnaire
Personal Training Health Screening Questionnaire Personal Information Today s date: Title: Dr. Mr. Mrs. Ms. Name: / Birth date: Last name First name Age: Address: Phone: (home) City: Phone: (work) Province:
*2PHT* REHAB SERVICES PATIENT HISTORY QUESTIONNAIRE
*2PHT* 2PHT Page 1 REHAB SERVICES PATIENT HISTORY QUESTIONNAIRE In order for us to fully address all aspects of your problem, the following information is needed. Please take time to complete this form.
THE CORRELATION BETWEEN PHYSICAL HEALTH AND MENTAL HEALTH
HENK SWINKELS (STATISTICS NETHERLANDS) BRUCE JONAS (US NATIONAL CENTER FOR HEALTH STATISTICS) JAAP VAN DEN BERG (STATISTICS NETHERLANDS) THE CORRELATION BETWEEN PHYSICAL HEALTH AND MENTAL HEALTH IN THE
Health Information Form for Adults
A. Identification B. Emergency Contacts Name (Last) (First) (Middle) Maiden Name In Case of Emergency, Notify: Primary Contact Name (Last) (First) (Middle) Primary Alternate Relationship Home Work Home