ADULT INTAKE FORM (13 and older) Name Date of First Visit Address City State Zip Code Telephone (home) (work) (cell) Is it ok to leave a message?
|
|
|
- Marjorie Day
- 5 years ago
- Views:
Transcription
1 ADULT INTAKE FORM (13 and older) Name Date of First Visit Address City State Zip Code Telephone (home) (work) (cell) Is it ok to leave a message? Age Date of Birth Gender Identity Relationship: Single Married Partnership Separated Divorced Widowed Live with: Spouse Partner Parents Children Friends Alone Roommates Occupation Hours per week Retired How did you hear about our clinic? Has any other family member already been a patient at the clinic? Emergency Contact Relationship Phone Are you currently receiving healthcare? Y N If yes, where and from whom? If no, when and where did you last receive medical or health care? What was the reason? What are your most important health problems? List as many as you can in order of importance. 1) 2) 3) 4)
2 Family History Age (if living) Mother Father Brothers Sisters Maternal GM Maternal GF Paternal GM Paternal GF Health (G=good, P=poor) Age at death (if deceased) Cause of Death Check those Applicable Cancer Diabetes Heart Disease High Blood Pressure Stroke Epilepsy Mental Illness Asthma/Hayfever/Hives Allergies Eczema/Psoriasis Anemia Kidney Disease Glaucoma Tuberculosis Other Did you have any of the following childhood illnesses and if so when? 1.) Scarlet Fever 4.) Measles 2.) Mumps 5.) Rheumatic Fever 3.) Diphtheria 6.) German Measles
3 For all of the following sections: Y = a condition you have now N = never had P = a condition you had previously Musculoskeletal Joint pain or stiffness Y N P Back/Neck pain Y N P Weakness Y N P Muscle spasms/cramps Y N P Arthritis Y N P Sciatica Y N P Blood/Peripheral Vasc. Easy bleeding/bruising Y N P Varicose veins Y N P Cold hands/feet Y N P Deep leg pain Y N P Anemia Y N P Mental/Emotional Treated for emotional problems Y N P Considered/ Attempted Suicide Y N P Memory loss Y N P Mood swings Y N P Depression Y N P History of Abuse Y N P Poor concentration Y N P Anxiety Y N P Endocrine Hypo/Hyperthyroid Y N P Diabetes Y N P Heat/Cold intoler. Y N P Night sweats Y N P Excessive thirst Y N P Weight loss/gain Y N P Hypoglycemia Y N P Fatigue Y N P Neurologic Seizures Y N P Paralysis Y N P Numbness/Tingling Y N P Vertigo or dizziness Y N P Skin Rashes Y N P Acne, Boils Y N P Hair loss Y N P Itching Y N P Color Change Y N P Head Headaches Y N P Migraines Y N P Head Injury Y N P Eyes Glaucoma Y N P Cataracts Y N P Impaired vision Y N P Glasses or contacts Y N P Blurriness Y N P Double vision Y N P Color blindness Y N P Tearing or dryness Y N P Ears Impaired hearing Y N P Ringing Y N P Earaches Y N P Nose and Sinuses Frequent colds Y N P Nose bleeds Y N P Loss of smell Y N P Hayfever Y N P Sinus problems Y N P
4 Neck Lumps Y N P Swollen glands Y N P Goiter Y N P Pain or stiffness Y N P Respiratory Cough Y N P Pneumonia Y N P Coughing up blood Y N P Wheezing Y N P Asthma Y N P Bronchitis Y N P Shortness of breath Y N P Tuberculosis Y N P Emphysema Y N P Cardiovascular Heart disease Y N P Angina Y N P Murmurs Y N P High/Low blood pressure Y N P Blood clots Y N P Fainting Y N P Palpitations/fluttering Y N P Swelling in ankles Y N P Chest pain Y N P Gastrointestinal Trouble swallowing Y N P Heartburn Y N P Hemorrhoids Y N P Change in appetite Y N P Nausea Y N P Vomiting Y N P Vomiting blood Y N P Blood in stool Y N P Pain or cramps Y N P Belching or passing gas Y N P Constipation Y N P Diarrhea Y N P Gall bladder disease Y N P Black stools Y N P Ulcer Y N P Jaundice (yellow skin) Y N P Liver disease Y N P How many bowel movements daily? Genito-urinary Pain on urination Y N P Incr. frequency Y N P Incontinence Y N P Frequency at night Y N P Frequent infections Y N P Kidney stones Y N P Condyloma (genit. warts) Y N P Chlamydia Y N P Gonorrhea Y N P Herpes Y N P Syphilis Y N P Male Reproduction Testicular masses Y N P Hernias Y N P Prostate disease Y N P Testicular pain Y N P Discharge Y N P Sores Y N P Premature ejaculation Y N P Are you sexually active? Y N Sexual orientation? Birth control type? Female Reprod./Breast Age of first menses Are cycles regular? Y N Length of cycle Duration of menses Date of last menses Clotting Y N P Bleeding between cycles Y N P Painful menses Y N P Light flow Y N P Heavy or excessive flow Y N P PMS Y N P PMS symptoms? Pain during intercourse Y N P Endometriosis Y N P Ovarian cysts Y N P Are you sexually active? Y N P Sexual orientation? Birth control type? Number of pregnancies # of Live births # of miscarriages
5 Number of abortions Abnormal PAP Y N P Breast self-exams? Y N P Breast pain/tenderness Y N P Breast lumps Y N P Nipple discharge Y N P Breast feeding Y N P Mastitis Y N P Menopause Y N P Menop. symptoms Please list any prescription medications, over the counter medications, vitamins, or supplements you are currently taking: 1) 3) 5) 7) 2) 4) 6) 8) Are you allergic to any medications or other substances? Y N If yes please explain: What hospitalizations or surgeries have you had? When did they occur?
(PLEASE CIRCLE YES ANSWERS ONLY)
(PLEASE CIRCLE YES ANSWERS ONLY) Childhood Illnesses Scarlet Fever Y N Diphtheria Y N Rheumatic fever Y N Mumps Y N Measles Y N German Measles Y N Hospitalizations and Surgery What hospitalizations or
Holly Zapf, ND -- Whole Family Health Clinic
Holly Zapf, ND -- Whole Family Health Clinic 2928 SE Hawthorne, Suite 106, Portland, OR 97214 phone: 503-460-0630 fax: 503-231-4003 wholefamily97214@gmail.com Name: Date: Address: City: State: Zip Code:
(Work address): How did you hear about our clinic? Has any other family member already been a patient at the clinic?
Name: Date: Address: City: State: Zip Code: Telephone # (home): (work): E-mail address: Age: Date of Birth: Gender: female male Education: Married: Separated: Divorced: Widowed: Single:_ Partnership:_
Portland Dental and Naturopathic Clinic
Portland Dental and Naturopathic Clinic Adult Intake Form Name Date of First Visit Address City State Zip Code Telephone # (home) (work) Cell Email address Age Date of Birth Gender: female male Education
DR.CRISTINA COLOMA, ND 2888 GARDNER COURT ABBOTSFORD, BC V2T 5H9 Phone/Fax (604)
DR.CRISTINA COLOMA, ND 2888 GARDNER COURT ABBOTSFORD, BC V2T 5H9 Phone/Fax (604) 556-4596 E-mail: abbynaturopath@gmail.com Name: Date: Address: City: Province/State: Zip/Postal Code: Telephone # (home):
Dr. Kevin Passero, N.D Lubrano Drive, Suite L 15, Annapolis, MD New Hampshire Ave Suite B4 NW Washington DC 20036
Dr. Kevin Passero, N.D. 443-433-5540 130 Lubrano Drive, Suite L 15, Annapolis, MD 21401 1330 New Hampshire Ave Suite B4 NW Washington DC 20036 Health History Form Name: Date: Address: City: State: Zip
Divine Medicine NW Greenbrier Parkway, Suite 100 Beaverton, Oregon P F
Divine Medicine 15455 NW Greenbrier Parkway, Suite 100 Beaverton, Oregon 97006 P 503.466.2722 F 503.644.1293 Patient Demographic Information: Patient Name Street Address Last Name First Name Middle Initial
INTAKE FORM ADULT. Contact Information. Date
INTAKE FORM ADULT Basic Information Dr Aoife M Earls, BSc, MSc Naturopathic Doctor Suite 212, 345 Lakeshore Rd E, Oakville, ON L6H 6K7 1.905.849.6730 draoife.com Date Name Date of Birth YYYY-MM-DD Sex
Naturopathic Intake Paperwork
3500 Kensington Ave Suite B- 2 Richmond, VA 23221 T/F 804-977- 2634 Naturopathic Intake Paperwork 1) What led you to choosing this clinic? 2) What do you know about us and how we work? 3) What three expectations
ADULT INTAKE. Name: Date: Address: City: Prov: PC: Telephone (home): (work): Age: Date of Birth: Gender: Female / Male
ADULT INTAKE Name: Date: Address: City: Prov: PC: Telephone (home): (work): Age: Date of Birth: Gender: Female / Male Married: Separated: Divorced: Widowed: Single: Partnership: Live with: Spouse: Partner:
Adaptive Play and Wellness. Miela Gruber Cooley ND Registration Form (Please Print)
KIDSPACE Adaptive Play and Wellness 469 Buckland Road South Windsor, CT 06074 phone (860) 432-9923 fax (860) 432-7553 Miela Gruber Cooley ND Registration Form (Please Print) Today s Date: PCP: Patient
East West Acupuncture & Wellness Center, Inc. Patient Intake Form
East West Acupuncture & Wellness Center, Inc. Patient Intake Form Date: / / How did you hear about us? ( )Ad ( ) Healthcare Referral ( ) Friend/Family Whom may we thank for the referral? Name DOB / / Age
Dr. Roxie Strand, NMD
Dr. Roxie Strand, NMD Name: Date: Address: City: State: Zip Code: Telephone # home: work: cell: E-mail address: Age: Date of Birth: Gender: female male Education: Married: Separated: Divorced: Widowed:
NAME: LAST FIRST MIDDLE INITIAL ADDRESS CITY STATE ZIP
45 West Crossville Road, Suite 501 Roswell, Georgia 30075 Phone 770-594-1233 Fax 770-594-0037 www.forrestsmithmd.com PERSONAL INFORMATION TODAY S DATE / / NAME: LAST FIRST MIDDLE INITIAL ADDRESS CITY STATE
Adult Intake. (Please print clearly) Name Date. Address. Address. Home Telephone Number. Emergency contact: Name
Adult Intake (Please print clearly) Name Date Date of birth (M/D/Y) Sex M F Address E-mail Address Home Telephone Number Work _ May we leave messages relating to your visits? Y / N Which Phone Number?
Natural Healing Family Medicine
Adult Intake Form Last Name: First Name: Date: Address: City: State Zip Telephone (Home): Telephone (Work): Email Address: Age: Date of Birth: Gender: Married: Separated: Divorced: Widowed: Single: Partnership:
Family members living at home with the patient: Patient s school: Emergency contact: Relationship: Phone:
Nature Cures Naturopathic Clinic Dr. Cathy Picard, Naturopathic Physician 250 Eddie Dowling Hwy., N.Smithfield, RI 02896 Phone: 401-597-0477 Fax: 401-597-0959 www.drcathypicard.com ADOLESCENT INTAKE FORM
c u l t i v a t e w e l l n e s s
Patient Information Name Age Date of birth Sex: Male Female Amy Bader, ND n atu r o p a t h i c d o c t o r Date Address City State Zip Telephone (Home) (Work) (Cell) Email Emergency Contact Relationship
NEW PATIENT INTAKE. Name: Date: Address: Preferred Phone: ( ) Alternate Phone:( ) Leaving Voice Message OK: Y N Preferred method of contact:
NEW PATIENT INTAKE Patient Information: Name: Date: Address: Preferred Phone: ( ) Alternate Phone:( ) Leaving Voice Message OK: Y N Preferred method of contact: E-mail address: Age: Date of Birth: / /
Patient Intake Form. Name Date of birth Age Sex: Male Female
Patient Intake Form Today s date: Name Date of birth Age Sex: Male Female Health Concerns: Please list your main health concerns in order of importance. 1. Describe your primary concern When did it start?
Yen Chiropractic, LLC Personal Injury Patient Intake Form Page 1
GENERAL INFORMATION: TODAY'S DATE: YEN CHIROPRACTIC DR. DANIEL D. YEN, D.C. 4528 W CRAIG RD, SUITE 190 NORTH LAS VEGAS, NV 89032 PATIENT NAME: SOCIAL SECURITY #: ADDRESS: CITY: STATE: ZIP: EMAIL: SEX:
Non Prolotherapy Patient Intake Form
Non Prolotherapy Patient Intake Form Scottsdale Pain Rehabilitation & Wellness Fred G. Arnold, N.M.D. 7595 East McDonald Drive, Suite 100 Scottsdale, AZ 85250 (O) 602 292-2978 Fax: 480-219- 8132 www.prolotherapyphoenix.com
H E A LT H H I S T O RY
H E A LT H H I S T O RY Name: : List All Current Health Problems: List Any Other Doctors Seen, Treatments And Results Obtained: Your Current Physician(s)/Therapist(s): List All Surgeries And Their s: List
Adult Intake - Prenatal
Du La, ND# 1135 Jonah Lusis, ND# 1248 T: 416 598 8898 Adult Intake - Prenatal Date: Name: Age: D.O.B.: Address: City: Postal Code: Telephone: (home) (work) (mobile) E-mail: Emergency contact: Relationship:
SONG OF NATURAL MEDICINE Dr. Crystal Song, NMD
Patient Intake Form DATE: Patient Name: List in Order of importance what your problems are: 1) 2) 3) DOB: Last time you had wellness checkup and with what physician: Family History Father Mother Siblings
Date of Birth Gender. List, in order of importance, your goals for working with your physician:
List, in order of importance, your goals for working with your physician: 1. 2. 3. 4. 5. Please list your allergies and what happens when you are exposed to the allergen: Drug Allergies: Food Allergies:
Address: City: State: Zip: Age: Birth Date: Marital Status: M S W D No. of Children. Your Employer: Occupation: Years on Job:
C O N F I D E N T I A L PAT I E N T I N F O R M AT I O N The following information is needed in order to better serve you. Please complete all questions. If you need help, please ask the receptionist.
Family History. Patient Name: DOB: List in Order of importance what your health concerns are: 1) 2) 3) 4) 5)
Naturopathic Heart Institute of Tucson, LLC June E. Stevens NMD Southwest Integrative Healthcare 2802 N. Alvernon Way, Suite 200 Tucson, AZ 85712 (520) 326-0850 (520) 326-0849 Patient Name: DOB: List in
Charlotte, NC (980) Roanoke, VA (540)
New Patient Information NAME: SEX: / / AGE: (Last) (First) ADDRESS: CITY: STATE: ZIP: HOME PHONE:( ) CELL PHONE: ( ) WORK PHONE: ( ) EMAIL ADDRESS: SSN: Would you like to receive our email newsletter?
CARY HOLISTIC HEALTH, LLC. Thank you for scheduling an appointment with Cary Holistic Health. Maggie Thibodeau, ND
Maggie Thibodeau, ND CARY HOLISTIC HEALTH, LLC 222 Ashville Avenue, Suite 10 / Cary, NC 27518 (919) 858-1004 / CaryHolisticHealth.com Thank you for scheduling an appointment with. We are located at 222
What are you seeking treatment for? Have you ever had acupuncture before? If so, for what condition?
Name Date What are you seeking treatment for? Have you ever had acupuncture before? If so, for what condition? Do you bruise or bleed easily? q Yes q No Pain l r b = left, right, both past current q q
Philip J Cimo DDS PA 650 West Bough Lane Ste #160 Houston TX
Philip J Cimo DDS PA 650 West Bough Lane Ste #160 Houston TX 770024 O: (713)464-1887 F: (713)461-0605 PATIENT INFORMATION Date: / / Patient Name: First MI Last Address: Date of Birth: Social Security #:
HEALTH HISTORY FORM. Patient Name: Birth Date: / / Supportive relationship(s)? Yes No Spiritual Practice? Yes No If yes,
HEALTH HISTORY FORM PERSONAL INFORMATION: Today s Date: Patient Name: Birth Date: / / Supportive relationship(s)? Yes No Spiritual Practice? Yes No If yes, Any pets/farm animals? Yes No If yes, Have you
What is your stress level(1- none 10- very stressful) Occupational Personal
Patient Information form (Please Print) Name: Date of Birth: How do you identify? Male Female Two-spirit Transgendered Intersexed Are you indigenous? If so, please identify Address Postal Code: Phone:
CHILDREN - Full Initial Intake Questionnaire:
Pittsburgh Alternative Health, Inc 20 Cedar Boulevard, Suite 303 Mt. Lebanon, PA 15228 Phone 412-563-1600 Fax 412-563-2040 www.pittsburghalternativehealth.com CHILDREN - Full Initial Intake Questionnaire:
Treatment Intake Form
Sally Valentine, PhD, LCSW 1 W. Camino Real, Suite 202, Boca Raton, FL 33432 drsallyvalentine@me.com 561.391.3305 Treatment Intake Form Please complete all information on this form and bring it to your
Integrative Medicine and Holistic Wellness Center 677 West Main Street Hyannis, MA 02601
Integrative Medicine and Holistic Wellness Center 677 West Main Street Hyannis, MA 02601 Informed Consent for Health Consultation: I herby authorize my practitioner to advise the use of the following therapies.
Arizona Integrative Medical Solutions 4657 S. Lakeshore Dr, Ste #1 Tempe, AZ
Arizona Integrative Medical Solutions 4657 S. Lakeshore Dr, Ste #1 Tempe, AZ 85282 480-284- 8155 Female Health History Patient Name: Date: DOB: Age: Street Address: City: State: Zip: Home phone: Work Phone:
SOUTH TEXAS BONE & JOINT
SOUTH TEXAS BONE & JOINT NEW PATIENT INFORMATION (PLEASE PRINT) DATE: PATIENT S NAME EMAIL DATE OF BIRTH AGE M/ F SOCIAL SECURITY # MAILING ADDRESS PERMANENT OR TEMPORARY CITY, STATE, ZIP CODE (AREA CODE)
Premier Pain Consultants
Premier Pain Consultants Advanced Solutions For Pain Relief Name: DOB: Who is your primary care physician/family doctor? What is the major reason you are coming to see the doctor (chief complaint): How
Sleeping Steroids (cortisone, predisone) Thyroid Tranquilizers Supplements: How often have you taken antibiotics? Childhood? Adulthood?
Name Date Sex M F DOB Age Blood Type Occupation Last school grade completed Health Concerns. Please list in order of importance. Rate severity (1 is low severity, 10 is high) and success (1 is no success,
The following information is needed in order to better serve you. Please complete all questions.
C O N F I D E N T I A L PAT I E N T I N F O R M AT I O N The following information is needed in order to better serve you. Please complete all questions. If you need help, please ask the receptionist.
Arizona Integrative Medical Solutions 4657 S. Lakeshore Dr, Ste #1 Tempe, AZ
Arizona Integrative Medical Solutions 4657 S. Lakeshore Dr, Ste #1 Tempe, AZ 85282 480-284-8155 Diabetic Health History Patient Name: Date: DOB: Age: Street Address: City: State: Zip: Home phone: Work
Phone number: When and how did your pain begin? (a date is required for Medicare and some insurance policies) Date of onset:
C H I R O P R A C T I C O R T H O P E D I C S A N D R E H A B I L I T A T I O N ILJXAi Pain Relief Clinics Please complete all sections. Full Name: Nickname: Gender: M F Age: Race: Date of Birth: I I Family
NUTRITIONAL PATIENT QUESTIONAIRE
NUTRITIONAL PATIENT QUESTIONAIRE 2114 Schofield Ave. Weston, WI 54476 GENERAL INFORMATION PLEASE PRINT DATE / / PATIENT NAME HOME ADDRESS CITY STATE ZIP CODE E-MAIL ADDRESS @ (We do not share your address)
NUTRITIONAL PATIENT QUESTIONAIRE
NUTRITIONAL PATIENT QUESTIONAIRE 2114 Schofield Ave. Weston, WI 54476 GENERAL INFORMATION PLEASE PRINT DATE / / PATIENT NAME HOME ADDRESS CITY STATE ZIP CODE E-MAIL ADDRESS @ (We do not share your address)
History of Present Illness
Dr. Paul D. Jantzi Brazos Valley Allergy & Asthma Clinics (979) 836-5582 or (800) 362-9633 History of Present Illness Office Visit Date: Time: Location: Patient Name: Primary Physician (PCP): Date of Birth:
Infant/Children Assessment sheet Medical- Surgical unit/ ICU
King Saud University Nursing college Maternity & Child Health Nursing Department NUR 327 Infant/Children Assessment sheet Medical- Surgical unit/ ICU Date: / / Date Received: / / ( ) On Time ( ) Late Student
: < : : @ B S : : : New Immigrant Survey Section D - Health
Section D: Health D1 {CP, IM, SP - Next I have some questions about your health. Would} {OS Would} you say your health is excellent, very good, good, fair, or poor? 1. EXCELLENT [D2; OS: E1a] 2. VERY GOOD
Supplementary Material
1 ORIGINAL RESEARCH ARTICLE Pharmacoeconomics 2008; 26 (1): Supplementary Material 1170-7690/08/001-0001/$48.00/0 2008 Adis Data Information BV. All rights reserved. Economic Burden of Bilateral Neovascular
PATIENT PROFILE PERSONAL INFORMATION
PATIENT PROFILE PERSONAL INFORMATION Date Date I attended information seminar Last Name First Name MI Date of Birth SS# Home Address Apt# City State Zip Code Telephone: Home( ) Work( ) Cell ( ) E-Mail
Autologous Bone Marrow Transplant Crossword Puzzle on Discharge Education. Adult Bone Marrow Transplant Autologous Bone Marrow Transplant Puzzle 1
Autologous Bone Marrow Transplant Crossword Puzzle on Discharge Education 1 Across 1. You will not be able to for at least three months following your transplant. This period may be shorter for patients
AUBURN UNIVERSITY ATHLETIC DEPARTMENT MEDICAL HISTORY QUESTIONNAIRE
AUBURN UNIVERSITY ATHLETIC DEPARTMENT MEDICAL HISTORY QUESTIONNAIRE NAME: SPORT: SOCIAL SECURITY #: SEX: BIRTHDATE: / / Please circle any of the following that you have, have had, or are now undergoing
COOK ISLANDS TE MARAE ORA
COOK ISLANDS MINISTRY OF HEALTH TE MARAE ORA ANNUAL STATISTICAL TABLES HEALTH STATISTICAL TABLES 2008-2010 MEDICAL RECORDS UNIT Rarotonga Hospital It should be noted that information contained in this
IKDC DEMOGRAPHIC FORM
IKDC DEMOGRAPHIC FORM Your Full Name Your Date of Birth / / Your Social Security Number - - Your Gender: q Male q Female Occupation Today s Date / / The following is a list of common health problems. Please
ANATOMY AND PHYSIOLOGY Revised 11/2010
ANATOMY AND PHYSIOLOGY Revised 11/2010 DESCRIPTION OF COURSE: Covers the basics of human anatomy and physiology including anatomical terminology, basic biochemistry, cells and tissues, and the integumentary,
Supplementary Appendix
Supplementary Appendix This appendix has been provided by the authors to give readers additional information about their work. Supplement to: Poordad F, Lawitz E, Kowdley KV, et al. Exploratory study of
AQI Detectives. Learning Objective: Understand the Air Quality Index and learn how to find the daily air quality. Subjects
AQI Detectives 8 A C T I V I T Y Learning Objective: Understand the Index and learn how to find the daily air quality. Subjects Health Social Studies Materials Computer with internet access Crayons, colored
Allogeneic Bone Marrow Transplant Crossword Puzzle on Discharge Education
Allogeneic Bone Marrow Transplant Crossword Puzzle on Discharge Education Across 1. If you have, it is important to inform their school that you must be notified of communicable diseases like measles,
1. Medical History - This will let us know about any previous medical problems and hopefully prevent any further problems.
Dear AU Tiger and Parents, Welcome to Auburn University! We are glad to have you join the Auburn family. We would like to ask that you review and complete the enclosed forms listed on the checklist below.
These are just basic training slides, may vary from standards. Basic First Aid. 1
These are just basic training slides, may vary from standards Basic First Aid www.askmaaz.com 1 What is 1 st Aid First Aid is an immediate and temporary care given to a victim of an accident or sudden
Childhood Nephrotic Syndrome
WORKSH EETS Childhood Nephrotic Syndrome Developed by Pediatric Nephrology Program British Columbia Children s Hospital British Columbia Provincial Renal Agency Vancouver, British Columbia, Canada RD EDITION
Study No: Title : Rationale: Phase: Study Period: Study Design: Centres: Indication: Treatment: Objectives: Statistical Methods:
The study listed may include approved and non-approved uses, formulations or treatment regimens. The results reported in any single study may not reflect the overall results obtained on studies of a product.
CASE REPORT FORM (April 2012)
CASE REPORT FORM (April 2012) Surveillance of Paediatric Dengue National Paediatric Hospital, Phnom Penh Kingdom of Cambodia Study contact: I am confident that the information supplied in this case record
WORKERS COMPENSATION HISTORY
WORKERS COMPENSATION HISTORY PATIENT NAME PHONE NUMBER ADDRESS CITY STATE ZIP CODE AGE BIRTHDATE ( ) MALE ( ) FEMALE SSN NAME OF COMPENSATION CARRIER (if known) PHONE EMPLOYER S NAME PHONE EMPLOYER S ADDRESS
January 2011 NCIC CTG MA.20 (RTOG Endorsed) -1. Opened: December 14, 1999 Closed: February 2, 2007
January 2011 NCIC CTG MA.20 (RTOG Endorsed) -1 NCIC CTG MA.20 (RTOG Endorsed) Protocol Status: Opened: December 14, 1999 Closed: February 2, 2007 Title: A Phase III Study of Regional Radiation Therapy
CHAPTER 8. Editors: Dr Omar Sulaiman Dr Hooi Lai Seong
CHAPTER 8 DECEASED (CADAVERIC) ORGAN Editors: Dr Omar Sulaiman Dr Hooi Lai Seong Expert Panel: Dr Omar Sulaiman (Chairperson) Dr Hooi Lai Seong Dr Rosnawati Yahya Dato' Dr Sharifah Suraya Syed Mohd Tahir
Broken Arrow Public Schools Physiology Objectives
1 st six weeks 1 Define anatomy and physiology. 2 Compare and contrast levels of structural organization. 3 Identify necessary life functions and essential needs and how they are related to homeostasis.
Passaic County Technical Institute. Wayne, NJ. Anatomy and Physiology II Curriculum. August 2015
Passaic County Technical Institute Wayne, NJ Anatomy and Physiology II Curriculum August 2015 Anatomy and Physiology II Curriculum August 2015 I. Course Description Anatomy and Physiology II is a full
RENCO ELECTRONICS, INC.
Directions: Complete sections 1, 2, and 3 for all accidents and incidents. Accidents or incidents that require medical attention or lost or restricted work require the signature of Human Resources. Attach
Supplementary webappendix
Supplementary webappendix This webappendix formed part of the original submission and has been peer reviewed. We post it as supplied by the authors. Supplement to: Elter T, Gercheva-Kyuchukova L, Pylylpenko
Anatomy & Physiology Curriculum Map Date Content/Topics Objectives Activities/Assessments Aug. 7th- 21st
Anatomy & Physiology Curriculum Map 2012-13 Date Content/Topics Objectives Activities/Assessments Aug. 7th- 21st Chapter 1 Body Regions/Cavities Directional Terms Homeostasis System Basics with introduction
Sioux Falls School District Anatomy and Physiology Holes Anatomy and Physiology Authors: Shier, Butler, and Lewis Glencoe/ McGraw hill
Sioux Falls School District Anatomy and Physiology Holes Anatomy and Physiology Authors: Shier, Butler, and Lewis Glencoe/ McGraw hill Semester 1 Chapter 1: Introduction to Human Anatomy and Physiology
JOINT STRATEGIC NEEDS ASSESSMENT (JSNA) Key findings from the Leicestershire JSNA and Charnwood summary
JOINT STRATEGIC NEEDS ASSESSMENT (JSNA) Key findings from the Leicestershire JSNA and Charnwood summary 1 What is a JSNA? Joint Strategic Needs Assessment (JSNA) identifies the big picture in terms of
NSABP PROTOCOL B-39 RTOG PROTOCOL 0413
NSABP PROTOCOL B-39 RTOG PROTOCOL 0413 A Randomized Phase III Study of Conventional Whole Breast Irradiation (WBI) Versus Partial Breast Irradiation (PBI) for Women with Stage 0, I, or II Breast Cancer
Critical Illness Cover
Critical Illness Cover Competitor Comparison This is not a consumer advertisement and should not be relied upon by private investors or any other persons for making financial decisions. Condition CI Extra
Hazard Communication & Globally Harmonized System (GHS)
Hazard Communication & Globally Harmonized System (GHS) Introductions Construction Safety Compliance Develop a Common Understanding of: 1. What do You Need to KNOW 2. What do You Need to DO Miscommunicated
= MOTION. Yang (+) Yin (-)
DEATH = STILLNESS LIFE = MOTION Figure 8 Above is the characteristic of life and death described throughout the course. MOTION Modern Language Yang (+) Yin (-) Figure 9 Ancient Language (penis) (vagina)
Protists and Humans. Section 12-3
Protists and Humans Section 12-3 Protists and Disease Key Idea: Protists cause a number of human diseases, including giardiasis, amebiasis, toxoplasmosis, trichomoniasis, cryptosporidiosis, Chagas disease,
When Your Head is Hurt
INVISIBLE INJURIES When Your Head is Hurt 1855 E. Dublin Granville Road, Suite 301 Columbus, OH 43229 800-934-9840 www.odvn.org www.odvncares.com This booklet was produced by the Ohio Domestic Violence
NORTH CENTRAL TEXAS COUNCIL OF GOVERNMENTS AREA AGENCY ON AGING
NORTH CENTRAL TEXAS COUNCIL OF GOVERNMENTS AREA AGENCY ON AGING Home By Choice Assessment (Information for internal use only; protected information may not be shared without participants consent) Relocation
Macroscopic vs. Microscopic T-Chart
Macroscopic vs. Microscopic T-Chart Life on Mars T-Chart Think: Macroscopic Microscopic Classify the following items as macroscopic or microscopic: grain of salt,, moss, grain of sand, plant cell, water
Removing Heavy Metals and Toxins From Our Bodies Has Been a Challenge Until Now...
Any information presented here is not to be understood as 'professional advice'. Warning: If You Are Concerned About Heavy Metals in your body, Here is Vital Information For You... Your health, even your
CHAPTER 8 DECEASED (CADAVERIC) ORGAN AND TISSUE DONATION. Editor: Datin Dr Fadilah Zowyah Lela Yasmin Mansor Dr Hooi Lai Seong
CHAPTER 8 DECEASED (CADAVERIC) ORGAN AND TISSUE DONATION Editor: Datin Dr Fadilah Zowyah Lela Yasmin Mansor Dr Hooi Lai Seong Expert Panel Datin Dr Fadilah Zowyah Lela Yasmin Mansor (Chairperson) Dr Hooi
PSYCHOSOMATICS COURSE PSYCHOSOMATICS MANUAL. Section E DEVELOPMENTAL ISSUES WORK IN PROGRESS - DO NOT COPY - FOR CORE ENERGETICS TRAINING USE, ONLY!
PSYCHOSOMATICS MANUAL Section E DEVELOPMENTAL ISSUES 1 DEVELOPMENTAL ISSUES IN HEALTH AND ILLNESS TISSUE LAYERS, ENERGETIC BLUE PRINT and PSYCHOSOMATIC UNITY Understanding the basic function of the tissue
Detox Your Body Quickly and Easily With Super Zeolite Powder
Detox Your Body Quickly and Easily With Super Zeolite Powder Are you constantly unwell? Do you keep going down with ailments? It could be you re your body is chock full of toxins which you must get rid
AT THE DOCTOR S TRANSCRIPT & NOTES
AT THE DOCTOR S TRANSCRIPT & NOTES DIALOGUE Doctor: Good morning, Mrs 1 Jones. What seems to be the problem? Patient: Well doctor, I ve got a sore 2 throat and a bad cough 3. I ve also got a headache 4.
NEW PATIENT APPLICATION
NEW PATIENT APPLICATION WHOM MAY WE THANK FOR REFFERING YOU TO OUR OFFICE: TODAYS DATE: PATIENT DEMOGRAPHICS: Name: Birth : - - Age: q M q F Address: City: State: Zip: Social Security: Email: Mobile#:
Initial Certification
Initial Certification Medical Physics Part 1 Content Guide Part 1 Content Guides and Sample Questions PLEASE NOTE: List of Constants and Physical Values for Use on the Part 1 Physics Exam The ABR provides
Heat and Cold in Medicine
Heat and Cold in Medicine Physical Basis of Heat and Temperature Matter is composed of molecules that are in motion, In gas or liquid the molecules move about hitting one another or the walls of the container;
L I V E W E L L, W O R K W E L L
I N S I D E T H I S I S S U E E M E R G E N C Y R O O M O R U R G E N T C A R E? 1 A R T I C L E 2 C O N T I N U E D H E A L T H Y 3 R E C I P E M A M M O G R A M S - H E A L T H Y D I N I N G O F F I
BIOLOGY 5090/21 Paper 2 Theory October/November 2016 MARK SCHEME Maximum Mark: 80. Published
Cambridge International Examinations Cambridge Ordinary Level BIOLOGY 5090/21 Paper 2 Theory October/November 2016 MARK SCHEME Maximum Mark: 80 Published This mark scheme is published as an aid to teachers
Comprehensive Health Report
1 Comprehensive Health Report Report Prepared By; Team Cyber Astro 2 Dear XYZ Please find our analysis for your complete Comprehensive Health Report. We thank you for giving us this opportunity to analyse
Supplementary Online Content
Supplementary Online Content Sellers MM, Keele LJ, Sharoky CE, Wirtalla C, Bailey EA, Kelz RR. Association of surgical practice patterns and clinical outcomes with surgeon training in university- or nonuniversity-based
U.S. Army Injury Surveillance Summary 2014
U.S. Army Injury Surveillance Summary 2014 Epidemiology and Disease Surveillance Portfolio Injury Prevention Program Website: http://phc.amedd.army.mil/organization/hq/deds/pages/injurypreventionprogram.aspx
Practice Exam 1 (Sep. 21, 2015)
Practice Exam 1 (Sep. 21, 2015) Name: 1. Computers in a shipment of 100 units contain a portable hard drive (PHD), solid-state memory (SSM), or both, according to the following table: Let A denote the
Policy and Notes. Competition Note!!!!! It is important to remember that the Unlimited record. for the BBORR is over 172 MPH!
Policy and Notes Please read the following carefully. If you have any questions or need clarification, please do not hesitate to contact Crystal Lopez at 432-336-2264 or email cvb@fortstockton.org. Crystal
Modeling and Reasoning with Bayesian Networks. p.1
Modeling and Reasoning with Bayesian Networks p. Software Packages for BNs Software Packages for Graphical Models / Bayesian Networks http://www.cs.ubc.ca/ murphyk/bayes/bnsoft.html SamIam from UCLA http://reasoning.cs.ucla.edu/samiam/downloads.php