Date of Birth Gender. List, in order of importance, your goals for working with your physician:
|
|
|
- Christian Lucas Simpson
- 5 years ago
- Views:
Transcription
1 List, in order of importance, your goals for working with your physician: Please list your allergies and what happens when you are exposed to the allergen: Drug Allergies: Food Allergies: Environmental Allergies: Family History Father Mother Siblings Grandparents Spouse Children Age if living: Age when died: Reason for death: Cancer type: High Blood Pressure: Y N Y N Y N Y N Y N Y N Heart Attack/Stroke: Y N Y N Y N Y N Y N Y N Heart Disease: Y N Y N Y N Y N Y N Y N Asthma/Allergies: Y N Y N Y N Y N Y N Y N Mental Illness: Y N Y N Y N Y N Y N Y N TB: Y N Y N Y N Y N Y N Y N Auto-Immune Disease: Y N Y N Y N Y N Y N Y N Diabetes Mellitus: Y N Y N Y N Y N Y N Y N Osteoporosis: Y N Y N Y N Y N Y N Y N List All Surgeries & Hospitalizations, including date occurred: Please note when and/or why you have had or were diagnosed with any of the following: X-Rays: Ultrasounds: TB Test: HIV: MRI/CAT Scan: Accidents: HCV: Flu Shot:
2 Last Dental Visit: Last eye exam: Did you have the following Disease (D), Been Vaccinated (V), or Neither (N): Measles D V N Hemophilia D V N Rubella D V N Mumps D V N Chicken Pox D V N Tetanus D V N Hep B D V N Whooping Cough D V N Rubeola D V N HIB D V N Any vaccination reactions? List Yes (Y), No (N), or Past (P) regarding use of the following: Antacids: Y N P Steroids: Y N P Coffee: Y N P Cups per day if Yes: Analgesics: Y N P Laxatives: Y N P Smoking: Y N P Packs per day & number of years: Soda Pop: Y N P Ounces or cans per day if Yes: Alcohol: Y N P How often & how much if Yes: Any Alcohol Addiction: Y N P Any Alcohol Treatment: Y N P Recreational Drugs: Y N P Any Drug Addictions: Y N P Any Drug Treatment: Y N P List all Prescription Medicines & Supplements/Herbs that you are taking and include dosage if known: Present Weight: Height: Weight one year ago: Maximum weight and when: Minimum weight as adult & when: Any weight questions or concerns?
3 Regarding the next long section: Please circle (Y) if you currently have the problem, (N) if you ve never had the problem and (P) if you had the problem in the past. Good Energy: Y N P Fatigue: Y N P Average Energy Level (Low) (High) If you have fatigue when is it the worst? If you have fatigue, can you do what you need to during the day? YES NO SKIN Rash: Y N P Color Change: Y N P Hives: Y N P Lump: Y N P Psoriasis/eczema: Y N P Itchy: Y N P Dry: Y N P Warts/moles: Y N P Cancer: Y N P Perspiration: Y N P HEAD Headache: Y N P Migraine: Y N P Dandruff: Y N P Head Injury: Y N P Oil/Dry Hair: Y N P Hair Loss: Y N P NOSE Frequent Colds: Y N P Nosebleeds: Y N P Congestion: Y N P Post Nasal Drip: Y N P Polyps: Y N P Seasonal Allergies: Y N P EYES Dry/Watery: Y N P Blurry Vision: Y N P Double Vision: Y N P Cataracts: Y N P Glaucoma: Y N P Styes: Y N P Strain: Y N P Discharge: Y N P Itchy: Y N P Dark Under Eyelid: Y N P MOUTH/THROAT Canker Sores: Y N P Cold Sores: Y N P Sore Throat: Y N P Gum Disease: Y N P Dentures: Y N P Cavities: Y N P Loss of Taste: Y N P Hoarseness: Y N P
4 NECK Stiffness: Y N P Swollen Glands: Y N P Full Movement: Y N P Tension: Y N P RESPIRATORY Cough: Y N P TB: Y N P Shortness of breath w/exertion: Y N P Bronchitis: Y N P Shortness of breath sitting: Y N P Pneumonia: Y N P Shortness of breath lying: Y N P Asthma: Y N P Wheezing: Y N P Painful breathing: Y N P CARDIOVASCULAR High Blood Pressure: Y N P Rheumatic Fever: Y N P Low Blood Pressure: Y N P Murmurs: Y N P Arrhythmias: Y N P Palpitations: Y N P Edema: Y N P Chest Pain: Y N P URINARY TRACT Incontinence: Y N P Pain w/urination: Y N P Frequent Infections: Y N P Kidney Stones: Y N P Urgency: Y N P Discharge/Blood: Y N P GASTROINTESTINAL Heartburn: Y N P Bowel Movement Freq: Indigestion: Y N P Recent BM Change: Y N P Bloating: Y N P Diarrhea/Constipation: Y N P Nausea: Y N P Hemorrhoids: Y N P Vomiting: Y N P Gall Bladder Disease: Y N P Change In Appetite: Y N P Liver Disease: Y N P Pancreatitis: Y N P Ulcer: Y N P MALE Testicular pain/swelling: Y N P Sexually Active: Y N P Hernia: Y N P S.T.D.: Y N P Discharge: Y N P Prostate Disease/Symptoms: Y N P Impotency: Y N P Sexual Orientation: Hetero Homo Bi
5 FEMALE Age Period Began: How Often Period Occurs: How long period lasts: Heavy menstrual bleeding: Y N P Menstrual cramping: Y N P Menstrual Pain: Y N P PMS: Y N P Food cravings: Y N P Times Pregnant: How many births: Miscarriages: Abortions: Last Pap Smear: Diagnosis: Any abnormal paps: Y N P When was abnormal: Menopausal since what age: Use of hormones: Y N P Type of hormones used: Healthy libido: Y N P Dry vagina: Y N P Sexually Active: Y N P Pain w/intercourse: Y N P Vaginitis: Y N P S.T.D.: Y N P Mammography: Y N P If Yes, what were results? Dexa Scan: If yes, what were results? Y N P Sexual Orientation: Hetero Homo Bi List any birth control used, age used and length of time used: MUSCULOSKELETAL Weakness: Y N P Arthritis: Y N P Stiffness: Y N P Leg Cramps: Y N P Tremors: Y N P Pain: Y N P NERVOUS Paralysis: Y N P Sciatica: Y N P Tingling/numbness: Y N P Carpal tunnel syndrome: Y N P Seizures: Y N P Fainting: Y N P MENTAL/EMOTIONAL Depression: Y N P Anger/irritability: Y N P Suicidal: Y N P High-strung/tense: Y N P Anxiety: Y N P Fear/Panic: Y N P Eating disorder: Y N P Psych Hospitalization: Y N P
6 EXERCISE How often do you exercise? What type of exercise? For how long? SLEEP How many hours per night? If you wake up frequently, what is the reason? Nightmares: Y N P Wake Refreshed: Y N P Sleep Walk: Y N P Grind teeth: Y N P Must nap during the day: Y N P Snore: Y N P TOXIN EXPOSURE Did you grow up near any refinery, polluted area or in a home with leaded paint? If so, what sort of pollution? Have you had any jobs where you were exposed to solvents, heavy metals, fumes or other toxic materials? YES NO Have you ever had health problems when you put in new carpeting, painted your home, had new cabinets or did other refurbishing? Are you particularly sensitive to perfumes, gasoline or other vapors? Do you use pesticides, herbicides or other chemicals around your home? SOCIAL Do you enjoy your job? Hours worked per week: Highest Level of Education: Active spiritual practice: Y N P Quality of significant relationship: History of sexual, mental/emotional, physical abuse: Y N P If so, at what age and by whom:
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
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?
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
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:
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 Diabetic Health History Patient Name: Date: DOB: Age: Street Address: City: State: Zip: Home phone: Work
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?
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
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
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?
(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
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
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?
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
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
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:
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
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:
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:
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
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
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
(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:_
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:
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
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
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.
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:
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 #:
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:
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
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
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
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
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:
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,
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
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
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
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: / /
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)
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
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
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.
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
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:
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.
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
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
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
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
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
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:
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.
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
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,
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
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
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
: < : : @ B S : : : Toxic Algae and Cyanobacteria in Recreational Waters. Rang Cho Miriam Moritz
Toxic Algae and Cyanobacteria in Recreational Waters Rang Cho Miriam Moritz Algae Large, diverse group of eukaryotic organisms Contain chlorophyll and/or other pigments green, brown or red colour Perform
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#:
PubH 7405: REGRESSION ANALYSIS MLR: BIOMEDICAL APPLICATIONS
PubH 7405: REGRESSION ANALYSIS MLR: BIOMEDICAL APPLICATIONS Multiple Regression allows us to get into two new areas that were not possible with Simple Linear Regression: (i) Interaction or Effect Modification,
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
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
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
Unit 1: Cells, Tissues, Organs, and Systems
Unit 1: Cells, Tissues, Organs, and Systems Big Ideas The cell is the basic scientific unit of all living things. Cells must interact with the external environment to meet their basic needs. Your health
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
BIOSTATISTICS METHODS FOR TRANSLATIONAL & CLINICAL RESEARCH DAY #4: REGRESSION APPLICATIONS, PART C MULTILE REGRESSION APPLICATIONS
BIOSTATISTICS METHODS FOR TRANSLATIONAL & CLINICAL RESEARCH DAY #4: REGRESSION APPLICATIONS, PART C MULTILE REGRESSION APPLICATIONS This last part is devoted to Multiple Regression applications; it covers
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.
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
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
CURRICULUM MAP. TIME CONTENT PAGE REF. SKILLS ASSESSMENT/ACTIVITIES Day 1-3
CURRICULUM MAP COURSE TITLE: Anatomy and Physiology DESCRIPTION TEXTBOOK Essentials of Anatomy and Physiology OF COURSE: 8 th ed: Elaine Marieb Integrated approach to human anatomy. Performance and lab
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
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,
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
Chemical Hazards. How Do Chemicals Get Into the Body? What Forms Do Chemicals Take?
FCTSHEET 1 Most workplaces use or store chemicals of one kind or another. Chemicals can cause a number of health effects if not properly controlled. How Do Chemicals Get Into the Body? In order to cause
Part 1: /15 Part 2: /77 Part 3: /16 Part 4: /24.5
John P. Stevens High School Invasive Species Captain s Tryout 2017 1 Name(s): Team: Part 1: /15 Part 2: /77 Part 3: /16 Part 4: /24.5 TOTAL SCORE: /132.5 2 Part 1: Species identification. Identify the
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
Bangor School Department Grade 7 Science
Bangor School Department Grade 7 Science Teacher: School: NOTE: This record of assessments must be submitted to the Assistant Superintendent s Office by end of the school year. Date: 4 = Exceeds 3 = Meets
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 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
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
THE ASTROLOGY OF COLON DISORDERS. analyzing severity and duration of illness. a lecture by DIANE L. CRAMER
THE ASTROLOGY OF COLON DISORDERS analyzing severity and duration of illness a lecture by DIANE L. CRAMER THE ASTROLOGY OF COLON DISORDERS analyzing severity and duration of illness an Original Article
Acids, Bases and ph. Biology Honors. Acidic, Basic or Neutral (indicate if strong or weak acid or base) Substance ph More H + More OH - Vitamin C
Biology Honors Name Acids, Bases and ph Substance ph More H + More OH - Acidic, Basic or Neutral (indicate if strong or weak acid or base) Vitamin C Tap water Hydrochloric acid (HCl) Sodium hydroxide (NaOH)
The Halogen Family By:Alexis H, Andres T
The Halogen Family By:Alexis H, Andres T What are the physical characteristics? The halogen family are non-metallic elements. Solids- Iodine, and Astatine Liquids- Bromine Gases- Fluorine, and Chlorine
GPS * Safety Summary for Hydrochloric Acid
GPS * Safety Summary for Hydrochloric Acid Select a Topic: Names Product Overview Manufacture of Product Product Description Product Uses Exposure Potential Health Information Environmental Information
Levels of Organization. Monday, December 5, 16
Levels of Organization The human body is structured into systems. Cells are the smallest unit of life. Calls similar in shape and function work together as tissues. Different types of tissues form organs
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
Grade 9 Science Review
G r a d e 9 S c i e n c e R e v i e w E n d o f Y e a r 2 0 1 6 P a g e 1 Grade 9 Science Review Chapter 1 - Organisation of matter 1. Find the density of a mysterious liquid with a mass of 4.5 grams and
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.
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;
Q U E S T I O N S. 2/ The sun sends us (several correct answers) Light Energy Fire Warmth Rain
1 Q U E S T I O N S 1/ The sun is: A star A planet 2/ The sun sends us (several correct answers) Light Energy Fire Warmth Rain 3/ Does the sun revolve around the Earth? Yes No 4/ The ozone layer protects
Department Curriculum and Assessment Outline
Department: Science Year Group: 10 Teaching, learning and assessment during the course: Combined Science 1 2 B1 Key concepts in Biology B2 Cells and control What are the structure and function of cells.
1. Why Dissect. Why are frogs a good model to use when studying the digestive system (as well as other systems)?
Name: Date: Period: Frog Dissection Virtual Lab Use the frog Dissection link that follows to answer the questions. http://www.mhhe.com/biosci/genbio/virtual_labs/bl_16/bl_16.html Introduction 1. Why Dissect.
Grading Scheme 2 nd, Semester Tests 30% Quizzes 15% Labs 10% Assignments 10% Exam 30% Participation 5%
San Pedro High School San Pedro Town Belize District Telefax: 226-2045 Email Address: esantizo@sphs.edu.bz 4 th Form BIOLOGY YEARLY CURRICULUM Text: BIOLOGY FOR CXC Credit Hours: 5 Teacher: Mr. Erick Santizo