Case Series Drug Analysis Print. MFR (minus studies):
|
|
|
- Delilah Stewart
- 9 years ago
- Views:
Transcription
1 Report Run Date: 25-Feb-2015 Data Lock Date: 23-Feb :00:10 Earliest Reaction Date: 01-Oct-2005 MedDRA Version: MedDRA 17.1 MFR (minus studies): M-M-RVAXPRO, MMR, MÆSLINGER OG FÅRESYGE OG RØDE HUNDE, PRIORIX Report Run Date: 25-Feb-2015, Page 1
2 Blood disorders Leukopenias NEC Leukopenia 1 0 Lymphatic system disorders NEC Lymphadenopathy 5 0 Neutropenias Neutropenia 1 0 Thrombocytopenias Immune thrombocytopenic purpura 4 0 Thrombocytopenia 1 0 Thrombocytoses Thrombocytosis 1 0 Blood disorders SOC TOTAL 13 0 Report Run Date: 25-Feb-2015, Page 2
3 Cardiac disorders Ischaemic coronary artery disorders Angina pectoris 1 0 Rate and rhythm disorders NEC Arrhythmia 1 0 Bradycardia 1 0 Cardiac disorders SOC TOTAL 3 0 Report Run Date: 25-Feb-2015, Page 3
4 Congenital disorders Central nervous system disorders congenital NEC Syringomyelia 1 0 Congenital disorders SOC TOTAL 1 0 Report Run Date: 25-Feb-2015, Page 4
5 Ear disorders Ear disorders NEC Ear pain 1 0 Ear pruritus 1 0 Hearing losses Deafness 1 0 Hearing impaired 2 0 Inner ear signs and symptoms Tinnitus 2 0 Ear disorders SOC TOTAL 7 0 Report Run Date: 25-Feb-2015, Page 5
6 Endocrine disorders Acute and chronic thyroiditis Autoimmune thyroiditis 1 0 Thyroid hyperfunction disorders Hyperthyroidism 1 0 Endocrine disorders SOC TOTAL 2 0 Report Run Date: 25-Feb-2015, Page 6
7 Eye disorders Ocular disorders NEC Eye swelling 2 0 Ocular infections, inflammations and associated manifestations Ocular hyperaemia 2 0 Visual disorders NEC Diplopia 1 0 Photopsia 1 0 Vision blurred 3 0 Visual impairment 3 0 Eye disorders SOC TOTAL 12 0 Report Run Date: 25-Feb-2015, Page 7
8 Gastrointestinal disorders Diarrhoea (excl infective) Diarrhoea 3 0 Gastrointestinal and abdominal pains (excl oral and throat) Abdominal pain upper 1 0 Gastrointestinal atonic and hypomotility disorders NEC Constipation 1 0 Gastrointestinal signs and symptoms NEC Dysphagia 1 0 Gingival haemorrhages Gingival bleeding 1 0 Malabsorption syndromes Coeliac disease 1 0 Nausea and vomiting symptoms Nausea 5 0 Vomiting 5 0 Oral soft tissue haemorrhages Mouth haemorrhage 1 0 Salivary gland enlargements Parotid gland enlargement 1 0 Gastrointestinal disorders SOC TOTAL 20 0 Report Run Date: 25-Feb-2015, Page 8
9 General disorders Asthenic conditions Asthenia 3 0 Fatigue 11 0 Malaise 4 0 Febrile disorders Pyrexia 62 0 Feelings and sensations NEC Chills 1 0 Gait disturbances Gait disturbance 8 0 General signs and symptoms NEC Crying 1 0 General physical health deterioration 2 0 Influenza like illness 4 0 Local reaction 1 0 Swelling 2 0 Healing abnormal NEC Impaired healing 1 0 Injection site reactions Injection site eczema 4 0 Injection site erosion 1 0 Injection site erythema 4 0 Injection site extravasation 2 0 Injection site granuloma 4 0 Injection site nodule 1 0 Injection site pain 8 0 Injection site papule 1 0 Injection site pruritus 8 0 Injection site rash 3 0 Injection site swelling 4 0 Mass conditions NEC Nodule 2 0 Pain and discomfort NEC Chest pain 1 0 Discomfort 1 0 Pain 4 0 Vaccination site reactions Vaccination site discolouration 2 0 Vaccination site granuloma 9 0 Vaccination site irritation 1 0 Vaccination site nodule 1 0 Vaccination site pain 2 0 Vaccination site pruritus 4 0 Vaccination site rash 1 0 General disorders SOC TOTAL Report Run Date: 25-Feb-2015, Page 9
10 Immune system disorders Allergic conditions NEC Allergy to metals 5 0 Hypersensitivity 2 0 Allergies to foods, food additives, drugs and other chemicals Reaction to drug excipients 8 0 Anaphylactic responses Anaphylactic reaction 1 0 Immune system disorders SOC TOTAL 16 0 Report Run Date: 25-Feb-2015, Page 10
11 Infections Bacterial infections NEC Tonsillitis bacterial 1 0 Candida infections Oral candidiasis 1 0 Dental and oral soft tissue infections Parotitis 3 0 Eye and eyelid infections Conjunctivitis 2 0 Herpes viral infections Herpes zoster 1 0 Male reproductive tract infections Orchitis 1 0 Mumps viral infections Mumps 1 0 Mycoplasma infections Mycoplasma infection 1 0 Rubella viral infections Rubella 2 0 Rubeola viral infections Measles 3 0 Measles post vaccine 1 0 Upper respiratory tract infections Nasopharyngitis 4 0 Rhinitis 2 0 Tonsillitis 1 0 Viral infections NEC Viral rash 1 0 Infections SOC TOTAL 25 0 Report Run Date: 25-Feb-2015, Page 11
12 Injuries Cerebral injuries NEC Concussion 1 0 Maladministrations Incorrect route of drug administration 1 0 Non-site specific injuries NEC Fall 3 0 Skin injuries NEC Contusion 2 0 Vaccination related complications Vaccination failure 1 0 Injuries SOC TOTAL 8 0 Report Run Date: 25-Feb-2015, Page 12
13 Investigations Cerebrospinal fluid tests (excl microbiology) CSF cell count abnormal 1 0 Coagulation and bleeding analyses Coagulation factor increased 1 0 Investigations NEC Quality of life decreased 1 0 Physical examination procedures and organ system status Weight decreased 1 0 Weight increased 1 0 Platelet analyses Platelet count decreased 2 0 Urinalysis NEC Protein urine 1 0 Vascular tests NEC (incl blood pressure) Blood pressure decreased 1 0 Virus identification and serology Morbillivirus test positive 1 0 Investigations SOC TOTAL 10 0 Report Run Date: 25-Feb-2015, Page 13
14 Metabolic disorders Appetite disorders Decreased appetite 5 0 Diabetes mellitus (incl subtypes) Diabetes mellitus 1 0 Food malabsorption and intolerance syndromes (excl sugar intolerance) Food intolerance 1 0 Total fluid volume decreased Dehydration 1 0 Metabolic disorders SOC TOTAL 8 0 Report Run Date: 25-Feb-2015, Page 14
15 Muscle & tissue disorders Arthropathies NEC Arthritis reactive 3 0 Arthropathy 1 0 Bone related signs and symptoms Bone pain 1 0 Connective tissue disorders NEC Connective tissue disorder 1 0 Joint related signs and symptoms Arthralgia 5 0 Joint swelling 1 0 Lupus erythematosus (incl subtypes) Systemic lupus erythematosus 1 0 Muscle pains Myalgia 3 0 Muscle weakness conditions Muscular weakness 2 0 Musculoskeletal and connective tissue pain and discomfort Back pain 1 0 Musculoskeletal pain 2 0 Neck pain 5 0 Pain in extremity 4 0 Musculoskeletal and connective tissue signs and symptoms NEC Growth retardation 1 0 Rheumatoid arthropathies Rheumatoid arthritis 1 0 Spine and neck deformities Scoliosis 1 0 Synovial disorders Synovitis 1 0 Muscle & tissue disorders SOC TOTAL 34 0 Report Run Date: 25-Feb-2015, Page 15
16 Nervous system disorders Absence seizures Petit mal epilepsy 1 0 Acute polyneuropathies Guillain-Barre syndrome 3 0 Polyneuropathy 1 0 Autonomic nervous system disorders Autonomic nervous system imbalance 1 0 Coordination and balance disturbances Ataxia 1 0 Balance disorder 4 0 Coordination abnormal 1 0 Cortical dysfunction NEC Aphasia 1 0 Demyelinating disorders NEC Acute disseminated encephalomyelitis 1 0 Demyelination 1 0 Developmental disorders cognitive Autism 3 0 Disturbances in consciousness NEC Altered state of consciousness 1 0 Syncope 4 0 Dyskinesias and movement disorders NEC Dyskinesia 1 0 Hypokinesia 1 0 Dystonias Opisthotonus 1 0 Encephalitis NEC Encephalitis post immunisation 1 0 Facial cranial nerve disorders Facial paresis 3 0 Generalised tonic-clonic seizures Generalised tonic-clonic seizure 1 0 Headaches NEC Headache 10 0 Memory loss (excl dementia) Amnesia 1 0 Mental impairment (excl dementia and memory loss) Disturbance in attention 1 0 Motor neurone diseases Motor neurone disease 1 0 Narcolepsy and hypersomnia Hypersomnia 1 0 Nervous system disorders NEC Motor dysfunction 2 0 Neurological signs and symptoms NEC Dizziness 5 0 Drooling 1 0 Presyncope 3 0 Optic nerve disorders NEC Optic neuritis 1 0 Paraesthesias and dysaesthesias Burning sensation 1 0 Hypoaesthesia 1 0 Report Run Date: 25-Feb-2015, Page 16
17 Nervous system disorders Nervous system disorders cont'd Paraesthesia 1 0 Paralysis and paresis (excl cranial nerve) Paralysis 1 0 Paresis 1 0 Seizures and seizure disorders NEC Convulsion 4 0 Epilepsy 2 0 Febrile convulsion 6 0 Status epilepticus 2 0 Speech and language abnormalities Dyslalia 1 0 Speech disorder 1 0 Speech disorder developmental 1 0 Nervous system disorders SOC TOTAL 79 0 Report Run Date: 25-Feb-2015, Page 17
18 Psychiatric disorders Behaviour and socialisation disturbances Social avoidant behaviour 1 0 Confusion and disorientation Confusional state 2 0 Dissociative states Dissociation 1 0 Disturbances in initiating and maintaining sleep Insomnia 2 0 Emotional and mood disturbances NEC Irritability 1 0 Fluctuating mood symptoms Mood swings 1 0 Personality disorders NEC Personality disorder 1 0 Pervasive developmental disorders NEC Autism spectrum disorder 1 0 Psychotic disorder NEC Psychotic disorder 1 0 Sleep disorders NEC Sleep disorder 1 0 Psychiatric disorders SOC TOTAL 12 0 Report Run Date: 25-Feb-2015, Page 18
19 Renal & urinary disorders Bladder and urethral symptoms Urinary retention 1 0 Renal & urinary disorders SOC TOTAL 1 0 Report Run Date: 25-Feb-2015, Page 19
20 Reproductive & breast disorders Testicular and epididymal disorders NEC Testicular pain 1 0 Testicular swelling 1 0 Reproductive & breast disorders SOC TOTAL 2 0 Report Run Date: 25-Feb-2015, Page 20
21 Respiratory disorders Breathing abnormalities Dyspnoea 1 0 Bronchospasm and obstruction Asthma 1 0 Coughing and associated symptoms Cough 2 0 Productive cough 1 0 Pharyngeal disorders (excl infections and neoplasms) Pharyngeal erythema 2 0 Tonsillar hypertrophy 1 0 Upper respiratory tract signs and symptoms Catarrh 3 0 Increased viscosity of nasal secretion 1 0 Oropharyngeal pain 2 0 Respiratory disorders SOC TOTAL 14 0 Report Run Date: 25-Feb-2015, Page 21
22 Skin disorders Alopecias Alopecia 1 0 Apocrine and eccrine gland disorders Hyperhidrosis 1 0 Bullous conditions Blister 1 0 Dermal and epidermal conditions NEC Skin induration 1 0 Dermatitis and eczema Dermatitis 1 0 Dermatitis atopic 1 0 Eczema 3 0 Eczema asteatotic 1 0 Dermatitis ascribed to specific agent Drug eruption 1 0 Erythemas Erythema 5 0 Rash erythematous 5 0 Nail and nail bed conditions (excl infections and infestations) Nail disorder 1 0 Papulosquamous conditions Rash papular 1 0 Photosensitivity and photodermatosis conditions Photosensitivity reaction 1 0 Pilar disorders NEC Hair growth abnormal 4 0 Pruritus NEC Pruritus 12 0 Rash pruritic 5 0 Purpura and related conditions Henoch-Schonlein purpura 1 0 Petechiae 3 0 Rashes, eruptions and exanthems NEC Rash 14 0 Rash generalised 3 0 Rash macular 2 0 Rash maculo-papular 2 0 Rash morbilliform 14 0 Skin and subcutaneous conditions NEC Excessive granulation tissue 2 0 Skin mass 3 0 Skin cysts and polyps Dermal cyst 1 0 Urticarias Cold urticaria 1 0 Urticaria 9 0 Skin disorders SOC TOTAL Report Run Date: 25-Feb-2015, Page 22
23 Social circumstances Disability issues Disability 1 0 Social circumstances SOC TOTAL 1 0 Report Run Date: 25-Feb-2015, Page 23
24 Surgical & medical procedures Inner ear therapeutic procedures Cochlea implant 1 0 Surgical & medical procedures SOC TOTAL 1 0 Report Run Date: 25-Feb-2015, Page 24
25 Vascular disorders Peripheral vascular disorders NEC Hot flush 1 0 Peripheral vasoconstriction, necrosis and vascular insufficiency Peripheral coldness 1 0 Raynaud's phenomenon 1 0 Vascular disorders SOC TOTAL 3 0 TOTAL REACTIONS FOR DRUG TOTAL REPORTS 173 Report Run Date: 25-Feb-2015, Page 25
VAERS_ID SYMPTOM1 SYMPTOMVERSION1 SYMPTOM2 SYMPTOMVERSION2 SYMPTOM3 SYMPTOMVERSION3 SYMPTOM4 SYMPTOMVERSION4 SYMPTOM5 SYMPTOMVERSION5 131806
VAERS_ID SYMPTOM1 SYMPTOMVERSION1 SYMPTOM2 SYMPTOMVERSION2 SYMPTOM3 SYMPTOMVERSION3 SYMPTOM4 SYMPTOMVERSION4 SYMPTOM5 SYMPTOMVERSION5 131806 Arthritis 8.10 Dizziness 8.10 Hypertension 8.10 Sinusitis 8.10
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
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
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
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
Safety and Efficacy of Deferasirox (ICL670) in Patients With Iron Overload Resulting From Hereditary Hemochromatosis
A service of the U.S. National Institutes of Health Trial record 1 of 1 for: CICL670A2202 Previous Study Return to List Next Study Safety and Efficacy of Deferasirox (ICL670) in Patients With Iron Overload
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
White, circular, biconvex, uncoated tablets with a score line on one side, plain on the other.
Nausicalm Cyclizine hydrochloride Ph. Eur. 50 mg Presentation White, circular, biconvex, uncoated tablets with a score line on one side, plain on the other. Uses Actions The active ingredient-cyclizine
LOEWENBERG SCHOOL OF NURSING LOEWENBERG SCHOOL OF NURSING HEALTH EXAMINATION FORM (FORM 003)
SECTION I: To be completed by STUDENT: Name: DOB: Address: Phone (H): Phone (C): Health History: Please complete the following information: Recent weight loss or gain Fatigue, fever, sweats Difficulty
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
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.)
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!!
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
Chiari Malformation: Symptoms
Chiari Malformation: Symptoms SYMPTOMS DIAGNOSIS LIVING WITH CHIARI TREATMENT Rick Labuda, Executive Director [email protected] 724-940-0116 Disclaimer: This presentation is intended for informational
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.
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
Human Normal Immunoglobulin Solution for Intravenous Infusion.
CONSUMER MEDICINE INFORMATION (CMI) OCTAGAM Human Normal Immunoglobulin Solution for Intravenous Infusion. OCTAGAM is available in single use bottles of 20 ml, 50 ml, 100 ml and 200 ml. OCTAGAM contains
Requirements for Medical Clearance: History and Physical exam within 6 months of applying for privileges
To: From: Re: Medical Staff Applicants K. Bruce Simmons, MD Director, Requirements for Medical Clearance EMPLOYEE/STUDENT HEALTH Jacobsen Hall 315-464-4260 (telephone) 315-464-5471 (fax) The New York Department
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
E/M LEVEL WORKSHEET. Category. Subcategory (if applicable) (new/established, etc.)
E/M LEVEL WORKSHEET STEP 1 : IDENTIFY THE CATEGORY AND SUBCATEGORY OF SERVICE Carefully read the documentation. Using the Table of Contents, identify the appropriate category/subcategory. Category Subcategory
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:
Overview. Geriatric Overview. Chapter 26. Geriatrics 9/11/2012
Chapter 26 Geriatrics Slide 1 Overview Trauma Common Medical Emergencies Special Considerations in the Elderly Medication Considerations Abuse and Neglect Expanding the Role of EMS Slide 2 Geriatric Overview
Severe rheumatoid arthritis (a disease that causes inflammation of the joints),where MabThera is given intravenously together with methotrexate.
EMA/614203/2010 EMEA/H/C/000165 EPAR summary for the public rituximab This is a summary of the European public assessment report (EPAR) for. It explains how the Committee for Medicinal Products for Human
Stepping toward a different treatment option LEARN WHAT ACTHAR CAN DO FOR YOU
FOR MS RELAPSES Stepping toward a different treatment option LEARN WHAT ACTHAR CAN DO FOR YOU As a person with multiple sclerosis (MS), you know firsthand the profound impact MS relapses can have on your
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:
Disability Evaluation Under Social Security
Disability Evaluation Under Social Security Revised Medical Criteria for Evaluating Endocrine Disorders Effective June 7, 2011 Why a Revision? Social Security revisions reflect: SSA s adjudicative experience.
Medical Surgical Nursing (Elsevier)
1 of 6 I. The Musculoskeletal System Medical Surgical Nursing (Elsevier) 1. Med/Surg: Musculoskeletal System: The Comprehensive Health History 2. Med/Surg: Musculoskeletal System: A Nursing Approach to
In non-hodgkin s lymphoma, MabThera is used to treat two types of the disease, both of which affect B-lymphocytes:
EMA/614203/2010 EMEA/H/C/000165 EPAR summary for the public rituximab This is a summary of the European public assessment report (EPAR) for. It explains how the Committee for Medicinal Products for Human
MOTOR VEHICLE ACCIDENT QUESTIONNAIRE
MOTOR VEHICLE ACCIDENT QUESTIONNAIRE Thank you in advance for taking the time to complete this form, this will help us to better assess all of your pain concerns and provide you with the best treatment.
The format of this leaflet was determined by the Ministry of Health and its content was checked and approved in May 2013.
The format of this leaflet was determined by the Ministry of Health and its content was checked and approved in May 2013 Havrix 720 Junior 1 NAME OF THE MEDICINAL PRODUCT Havrix 720 Junior 2 QUALITATIVE
Key Facts about Influenza (Flu) & Flu Vaccine
Key Facts about Influenza (Flu) & Flu Vaccine mouths or noses of people who are nearby. Less often, a person might also get flu by touching a surface or object that has flu virus on it and then touching
1584 Wesleyan Drive FORM A Norfolk, VA 23504 Phone: (757) 455-3108 Health History immunization & Physical Form
Mail completed form to: Marlin Health Services 1584 Wesleyan Drive FORM A Norfolk, VA 23504 Phone: (757) 455-3108 Health History immunization & Physical Form Virginia State law (code 23-7.5) requires all
Things You Should Know About Adverse Event Report Data
U.S. Department of Health and Human Services Food and Drug Administration Center for Food Safety and Applied Nutrition CFSAN Adverse Event Reporting System Voluntary Reports on Red Bull Energy Drink January
TRINITAS SCHOOL OF NURSING STUDENT HEALTH RECORD
TRINITAS SCHOOL OF NURSING STUDENT HEALTH RECORD Please complete this form to the best of your ability and bring it to your Physician, Nurse Practitioner or Physician s Assistant for your physical examination.
U.S. Department of Health and Human Services Food and Drug Administration Center for Food Safety and Applied Nutrition
U.S. Department of Health and Human Services Food and Drug Administration Center for Food Safety and Applied Nutrition CFSAN Adverse Event Reporting System Voluntary and Mandatory Reports on 5-Hour Energy,
Medical Terminology APS-100-TE. TECEP Test Description
Medical Terminology APS-100-TE This TECEP tests the material usually taught in a course on the everyday medical terminology used by healthcare and medical professionals. It focuses on the word parts, word
Essential Shared Care Agreement Drugs for Dementia
Ref No. E040 Essential Shared Care Agreement Drugs for Dementia Please complete the following details: Patient s name, address, date of birth Consultant s contact details (p.3) And send One copy to: 1.
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
Department of State Academic Exchanges Participant Medical History and Examination Form
Department of State Academic Exchanges Participant Medical History and Examination Form Having been selected to participate in a U.S. Department of State educational exchange program, you are required
What Medical Emergencies Should a Dental Office be Prepared to Handle?
What Medical Emergencies Should a Dental Office be Prepared to Handle? Gary Cuttrell, DDS, JD, University of NM Division of Dental Services Santiago Macias, MD, First Choice Community Healthcare Dentists
Long Term Use of Antacid Medications Can Cause an Increased Risk for Osteoporosis and Much More
Long Term Use of Antacid Medications Can Cause an Increased Risk for Osteoporosis and Much More By: Jeremie Pederson D.C., C.S.C.S. Many people are concerned about the FDA news release dated May 25, 2010
Notice of Privacy Practices
Notice of Privacy Practices This notice describes how medical information about you may be used and disclosed, and how you may obtain access to this information. Please review it carefully. OMAC respects
Non-covered ICD-10-CM Codes for All Lab NCDs
Non-covered ICD-10-CM s for All Lab NCDs This section lists codes that are never covered by Medicare for a diagnostic lab testing service. If a code from this section is given as the reason for the test,
HEALTH SERVICES DEPARTMENT HEALTH HISTORY & PHYSICAL EXAM FORM HEALTH INFORMATION TECHNOLOGY
HEALTH SERVICES DEPARTMENT HEALTH HISTORY & PHYSICAL EXAM FORM HEALTH INFORMATION TECHNOLOGY Purpose: Completion of this packet is requested as part of the admissions process. The information you provide
Core Safety Profile. Pharmaceutical form(s)/strength: 50mg tablets IE/H/PSUR/0028/002 Date of FAR: 17.07.2013
Core Safety Profile Active substance: Naltrexone Hydrochloride Pharmaceutical form(s)/strength: 50mg tablets P-RMS: IE/H/PSUR/0028/002 Date of FAR: 17.07.2013 4.2 Posology and method of administration
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
Breast Cancer. Breast Cancer Page 1
Breast Cancer Summary Breast cancers which are detected early are curable by local treatments. The initial surgery will give the most information about the cancer; such as size or whether the glands (or
UBISTESIN 1:200,000 and UBISTESIN FORTE 1:100,000
UBISTESIN 1:200,000 and UBISTESIN FORTE 1:100,000 Articaine hydrochloride and adrenaline hydrochloride Consumer Medicine Information WHAT IS IN THIS LEAFLET Please read this leaflet carefully before you
PATIENT SELF-ASSESSMENT FORM
PATIENT SELF-ASSESSMENT FORM Please complete the information below to the best of your ability. Personal Information Name: Address: City: State: Zip: Telephone: Email: Name of referring physician: Address:
Southwest General Surgical Associates General & Vascular Surgery 8230 Walnut Hill Lane Suite 408 Dallas, TX 75231 Phone-214)369-5432 Fax-214)369-5591
Southwest General Surgical Associates General & Vascular Surgery 8230 Walnut Hill Lane Suite 408 Dallas, TX 75231 Phone-214)369-5432 Fax-214)369-5591 Andres U. Katz, M.D. Richard S. Anderson, M.D. G. Thomas
CHRONIC FATIGUE SYNDROME/FIBROMYALGIA SYMPTOM CHECKLIST (c) 1997 Katrina Berne, Ph.D., Mesa, AZ www.livingwithillness.com
CHRONIC FATIGUE SYNDROME/FIBROMYALGIA SYMPTOM CHECKLIST (c) 1997 Katrina Berne, Ph.D., Mesa, AZ www.livingwithillness.com Please indicate on a scale of 1 to 10, with 10 being the most severe, the severity
Testosterone Therapy for Women
Testosterone Therapy for Women The Facts You Need Contents 2 INTRODUCTION: The Facts You Need... 3-4 CHAPTER 1: Testosterone and Women... 5-9 CHAPTER 2: Testosterone Therapy for Women... 10-14 CONCLUSION:
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
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
Management in the pre-hospital setting
Management in the pre-hospital setting Inflammation of the joints Two main types: Osteoarthritis - cartilage loss from wear and tear Rheumatoid arthritis - autoimmune disorder Affects all age groups,
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
Types of Brain Injury
Types of Brain Injury The bones of your skull are hard and they protect your brain. Your brain is soft, like firm Jell-O. When your head moves, your brain moves inside your skull. When your head is hit
The format of this leaflet was determined by the Ministry of Health and its content was checked and approved in September 2008 HAVRIX 1440
The format of this leaflet was determined by the Ministry of Health and its content was checked and approved in September 2008 HAVRIX 1440 HAVRIX 720 Junior Monodose TITLE Hepatitis A (inactivated) vaccine
IMPORTANT: PLEASE READ
PART III: CONSUMER INFORMATION combined hepatitis A (inactivated) and hepatitis B (recombinant) vaccine This leaflet is part III of a three-part "Product Monograph" published when was approved for sale
Managing the Symptoms of Multiple Sclerosis. Yolanda Harris, MSN, CRNP-AC CPODD Nurse Practitioner
Managing the Symptoms of Multiple Sclerosis Yolanda Harris, MSN, CRNP-AC CPODD Nurse Practitioner What is Multiple Sclerosis An autoimmune disease that affects the central nervous system (CNS) The immune
Normal Age Related Changes and Developmental Disability
Normal and Developmental Disability Excerpts From: Growing Older with A Developmental Disability: Physical and Cognitive Changes and Their Implications. University of Illinois at Chicago VISION: Changes
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
REGISTRATION FORM PATIENT NAME: ADDRESS (STREET, CITY, STATE, ZIP): HOME PHONE: WORK PHONE: CELL PHONE: DATE OF BIRTH: / / AGE: SEX:
REGISTRATION FORM PATIENT NAME: ADDRESS (STREET, CITY, STATE, ZIP): HOME PHONE: WORK PHONE: CELL PHONE: E-MAIL ADDRESS: OCCUPATION: DATE OF BIRTH: / / AGE: SEX: SOCIAL SECURITY NUMBER: MARITAL STATUS:
National Cancer Institution (NCI) Toxicity Criteria
National Cancer Institution (NCI) Toxicity Criteria Toxicity Grade 0 1 2 3 4 Blood/Bone Marrow WBC?4.0 3.0-3.9 2.0-2.9 1.0-1.9
Vaccinations and Spina Bifida and Hydrocephalus
shinecharity.org.uk [email protected] 42 Park Road Peterborough PE1 2UQ 01733 555988 Vaccinations and Spina Bifida and Hydrocephalus Vaccines are made from parts of bacteria or viruses that cause
Headaches. This chapter will discuss:
C H A P T E R Headaches 1 1 Almost everyone gets an occasional headache at some time or another. Some people get frequent headaches. Most people do not worry about headaches and learn to live with them
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,
Drug Analysis Print Drug name: HUMAN PAPILLOMA VIRUS
Jump to first report page Report type: Total number of reactions*: 9742 Total number of ADR reports: 1601 Total number of fatal ADR reports: 2 Products included in this print - Multi active products (PBGs):
Summary of the risk management plan (RMP) for Accofil (filgrastim)
EMA/475472/2014 Summary of the risk management plan (RMP) for Accofil (filgrastim) This is a summary of the risk management plan (RMP) for Accofil, which details the measures to be taken in order to ensure
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
READ THIS FOR SAFE AND EFFECTIVE USE OF YOUR MEDICINE PATIENT MEDICATION INFORMATION. [new-ka la]
READ THIS FOR SAFE AND EFFECTIVE USE OF YOUR MEDICINE PATIENT MEDICATION INFORMATION Pr NUCALA [new-ka la] mepolizumab lyophilized powder for subcutaneous injection Read this carefully before you start
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
SLEEP DISORDERS CENTER SLEEP CLINIC PATIENT QUESTIONNAIRE. Please bring this completed questionnaire with you to your sleep clinic appointment.
SLEEP DISORDERS CENTER Please bring this completed questionnaire with you to your sleep clinic appointment. Patient s Name: Date: Referring Physician: Clinic Location: 1. Why are you being seen in the
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
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
Lumbar Laminectomy and Interspinous Process Fusion
Lumbar Laminectomy and Interspinous Process Fusion Introduction Low back and leg pain caused by pinched nerves in the back is a common condition that limits your ability to move, walk, and work. This condition
MEDICAL EXAM QUESTIONNAIRE APPLICATION SUPPLEMENT
Hartford Life Insurance Company Hartford Life and Annuity Insurance Company MEDICAL EXAM QUESTIONNAIRE APPLICATION SUPPLEMENT INSTRUCTIONS FOR THE MEDICAL EXAMINER DETACH AND DISCARD BEFORE MAILING THE
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
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
The Complete list of NANDA Nursing Diagnosis for 2012-2014, with 16 new diagnoses. Below is the list of the 16 new NANDA Nursing Diagnoses
The Complete list of NANDA Nursing Diagnosis for 2012-2014, with 16 new diagnoses. Below is the list of the 16 new NANDA Nursing Diagnoses 1. Risk for Ineffective Activity Planning 2. Risk for Adverse
2 P age. Babies from Birth to Age 2
Contents Babies from Birth to Age 2... 2 Vaccines give parents the power... 2 Vaccines are recommended throughout our lives... 3 Talk to your doctor... 3 Vaccines are very safe... 3 Whooping Cough (Pertussis)...
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
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
NAME: PROGRAM: Student Medical Form for North Carolina Community College System Institutions
NAME: PROGRAM: Student Medical Form for North Carolina Community College System Institutions Revised 2 REPORT OF MEDICAL HISTORY (Please print PAGE in black 2 BLANK ink) FOR INDIVIDUAL To be completed
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
Muscular Dystrophy and Multiple Sclerosis. ultimately lead to the crippling of the muscular system, there are many differences between these
Battles 1 Becky Battles Instructor s Name English 1013 21 November 2006 Muscular Dystrophy and Multiple Sclerosis Although muscular dystrophy and multiple sclerosis are both progressive diseases that ultimately
ICD-9-CM coding for patients with Traumatic Brain Injury*
ICD-9-CM coding for patients with Traumatic Brain Injury* The diagnostic code for sequelae of traumatic brain injury is: 907.0 Late effect of intracranial injury without mention of skull fracture (Late
Patient Medical History
Cardiovascular Abnormal Electrocardiogram Aortic Stenosis Atrial fibrillation Cardiac arrest Chest pain Congestive heart failure Heart valve replacement Hypertension Murmur Heart attack Palpitations Peripheral
WET, COUGHING AND COLD NEAR RIVER BANK STUNG BY BEE CAUSING ANAPHYLACTIC SHOCK TO WRIST
GRIT IN EYE BROKEN LEG BONE WET, COUGHING AND COLD NEAR RIVER BANK STUNG BY BEE CAUSING ANAPHYLACTIC SHOCK HEART ATTACK SUFFERING FROM SHOCK CHOKING SEVERE BLEEDING TO WRIST HYPOTHERMIA ANGINA Localised
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
SYNACTHEN i.m./i.v. tetracosactide hexaacetate
New Zealand Consumer Medicine Information SYNACTHEN i.m./i.v. tetracosactide hexaacetate 250 micrograms/ml solution for injection or infusion What is in this leaflet This leaflet answers some common questions
