History of Present Illness

Size: px
Start display at page:

Download "History of Present Illness"

Transcription

1 Dr. Paul D. Jantzi Brazos Valley Allergy & Asthma Clinics (979) or (800) History of Present Illness Office Visit Date: Time: Location: Patient Name: Primary Physician (PCP): Date of Birth: PCP Phone #: PCP Address: Chief Complaint (What main problem can the doctor help you with today?) Location (Circle your single worst symptom) Eyes Ears Nose Mouth Throat Lungs Skin Other: Quality (Circle what your single worst symptom feels like) Itching Burning Sneezing Coughing Rash Nasal Congestion Chest Congestion Chest Tightness Hives / Welts Skin Swelling Clear Mucus Colored Mucus (Indicate color: Green / Yellow / Brown / Grey) Other: Timing Is there a time of day that is worse? ( 6AM / 9AM / Noon / 3PM / 6PM / 9PM / Midnight / 3AM ) Is there a season of the year that is worse? ( Fall / Winter / Spring / Summer) Context Are your symptoms worse: When the air is cold? ( Y / N ) When you catch a cold? ( Y / N ) For 2 or more weeks after you catch a cold? ( Y / N ) When you have acid reflux? ( Y / N ) With exercise? ( Y / N ) If so, how long after you start the exercise? Other? Severity (Do these symptoms affect your life?) On a scale of 0 to 10, how bad does it get? ( 0 / 1 / 2 / 3 / 4 / 5 / 6 / 7 / 8 / 9 / 10 ) When you feel your best, how bad is it? ( 0 / 1 / 2 / 3 / 4 / 5 / 6 / 7 / 8 / 9 / 10 ) Duration How long have you had these problems? How old were you when it started? How long has it been this severe? Modifying Factors What medications help? (Antihistamines/Steroids/Singulair/Albuterol/Antacid/Other ) What medications didn't help? (Antihistamines/Steroids/Singulair/Albuterol/Antacid/Other ) What animals make symptoms worse? (dogs / cats / birds / horses / cows / ) What buildings make symptoms worse? (school / office / home / ) Allergy Clinic - Initial History and Physical page 1

2 Associated Signs and Symptoms (Other than your primary symptom, which of these do you have?) Itching eyes ( Y / N ) Burning eyes ( Y / N ) Watering eyes ( Y / N ) Itching of nose ( Y / N ) Sneezing ( Y / N ) Nasal congestion ( Y / N ) Headaches ( Y / N ) Excess mucus ( Y / N ) Post-nasal drip ( Y / N ) Clear mucus ( Y / N ) Colored mucus ( Y / N Green / Yellow / Brown / Grey ) Cough with exercise ( Y / N ) Cough from post-nasal drip ( Y / N ) Cough when you lie down ( Y / N ) Cough worst at 1-2AM ( Y / N ) Shortness of breath at rest ( Y / N ) Shortness of breath with exertion ( Y / N ) Dry and dark or ashy skin ( Y / N ) Hives or welts ( Y / N ) Skin swelling ( Y / N ) Other: Review of Systems Have you recently had any of the following problems? If so, how long and how often? General: Fever? ( Y / N ) Weight change? ( Y / N ) Sweating at night? ( Y / N ) Skin: Dryness? ( Y / N ) Eczema? ( Y / N ) Rash? ( Y / N ) Eyes: Itching? ( Y / N ) Redness? ( Y / N ) Watering? ( Y / N ) Swollen lids? ( Y / N ) Dark circles? ( Y / N ) Ears/Nose/Mouth/Throat: Ear infections? ( Y / N ) Sinus infections? ( Y / N ) Enlarged tonsils? ( Y / N ) Hoarseness? ( Y / N ) Respiratory: Snoring? ( Y / N ) Waking up gasping? ( Y / N ) Chronic cough? ( Y / N ) Pneumonia? ( Y / N ) Bronchitis? ( Y / N ) Asthma? ( Y / N ) Emphysema? ( Y / N ) Gastrointestinal: Heartburn or Sour taste? ( Y / N ) Stomach pains? ( Y / N ) Bloody or dark/tarry stools? ( Y / N ) Constipation? ( Y / N ) Diarrhea? ( Y / N ) Allergy Clinic - Initial History and Physical page 2

3 Psychiatric: Depression? ( Y / N ) Anxiety? ( Y / N ) Panic? ( Y / N ) Manic episodes? ( Y / N ) (A manic episode may involve little sleep, talking way too much and annoying your friends, spending sprees, multiple sex partners, or other risky behavior abnormal for you, such as getting piercings or tattoos, etc.) Allergy / Immunology: Food allergies? ( Y / N ) Insect allergies? ( Y / N ) Metal allergies? ( Y / N ) Plant allergies? ( Y / N ) Abnormal infections? (Bone / Gum / Muscle / Other Too many sinus infections and pneumonias? ( Y / N ) Musculo-skeletal: Arthritis? ( Y / N ) Swollen joints? ( Y / N ) Broken bones? ( Y / N ) Muscle weakness? ( Y / N ) Cardiovascular: Chest pains? ( Y / N ) Heart attack? ( Y / N ) Heart failure? ( Y / N ) Leg swelling? ( Y / N ) Abnormal rhythms? ( Y / N ) Atrial fibrillation? ( Y / N ) Neurologic: Seizures? ( Y / N ) Headache? ( Y / N Migraine / Cluster / Tension / Unsure ) Stroke or TIA? ( Y / N ) Endocrine: Diabetes? ( Y / N ) Thyroid problems? ( Y / N ) Hair loss? ( Y / N ) Recent weight gain? ( Y / N ) Heme / Lymphatic: Abnormal clotting? ( Y / N ) Abnormal bleeding? ( Y / N ) Anemia? ( Y / N ) Swelling of one arm or leg? ( Y / N ) Genito-urinary: Burning with urination? ( Y / N ) Abnormal smell of urine? ( Y / N ) Difficulty urinating? ( Y / N ) Long or heavy periods? ( Y / N ) Irregular periods? ( Y / N ) Allergy Clinic - Initial History and Physical page 3

4 Previous Medical History Previous surgeries? Chronic medical conditions (especially those for which you take medications)? Medications you regularly take: Medications you occasionally take: Supplements or herbs you use: Medication allergies: Medication Reaction Family Medical History Which of your blood relatives have had the following? Nasal allergies ( Mother / Father / Brother / Sister / Child / Other ) Sinus infections ( Mother / Father / Brother / Sister / Child / Other ) Asthma ( Mother / Father / Brother / Sister / Child / Other ) Bronchitis ( Mother / Father / Brother / Sister / Child / Other ) Pneumonia ( Mother / Father / Brother / Sister / Child / Other ) Any other significant medical problems? Social History Where do you live? ( City / Country ) What kind of building? ( House / Trailer Home / Apartment ) What pets are in the home? ( Dog / Cat / Bird / Other ) Are there any signs of water damage or mold? ( Y / N ) Do you smoke? ( Y / N ) Did you ever smoke? ( Y / N ) How many packs per day? ( less than ½ / ½ / 1 / 2 / 3 ) For how many years? How many alcoholic beverages do you drink per week? ( less than 1 / 1 / 2 / 4 / 8 / more ) Please list current and prior employers, years worked, and potential chemical or allergen exposures: Employer Years worked Potential chemical or allergen exposures Allergy Clinic - Initial History and Physical page 4

5 Physical Exam (to be completed by the physician) Constitutional Vital Signs(3): Height Weight P R BP General appearance: ( Slender / Average / Obese ) ( Clean / Average / Unkept ) Neurological Speech: ( Normal / Slurred / Other ) Facies: ( Normal / Mild weakness / Moderate / Profound ) ( Right / Left ) Motor/Reflexes: Sensation: Psychiatric Affect: ( Normal / Labile / Monotonous / Flat / Elated ) Insight: ( Normal / Limited<80 / Expanded>120 ) Memory: Recent: ( Normal / Mild / Moderate / Profound Loss ) Remote: ( Normal / Mild / Moderate / Profound Loss ) Eyes Lids & Conj: ( normal / edematous / Dennie Morgan lines ) ( normal / mild inj / mod inj / severe inj ) Pupils & Irises: ( equal & round / not equal / not round ) ( reactive / mildly reactive / nonreactive ) Ophthalmoscopic: Ears / Nose / Mouth / Throat External ears & nose: ( Pinna normal / anteverted R / L ) ( Nose midline / deviated R / L ) TM's & external canals: ( Normal R / L / Fluid-filled R / L / Some fluid R / L / Bulging R / L Pus behind TM R / L / Injected R / L ) ( EC normal R / L / Red R / L / Edematous R / L ) Hearing: ( Never misses words / Sometimes misses words / Consistent trouble / Hearing aid R / L ) Nares: Septum ( Normal / Upper R / L / Lower R / L / Posterior R / L / Spur R / L ) Inferior Turbinates ( Right 1+ / 2+ / 3+ / 4+ ) ( Left 1+ / 2+ / 3+ / 4+ ) Mucosa ( Right normal / sl / mod / severely boggy ) ( Left normal / sl / mod / severely boggy ) Mucus ( Right normal / stringy / thick / purulent ) ( Left normal / stringy / thick / purulent ) Mouth: Uvula ( Normal / removed / slender & long / thick / edematous ) Tonsils ( Right 1+ / 2+ / 3+ / 4+ / convoluted / pus ) ( Left 1+ / 2+ / 3+ / 4+ / convoluted / pus ) Posterior ( clear / mild cobblestoning / severe cobblestoning / accessory tonsillar tissue ) Neck Thyroid: ( Normal / Enlarged / Nodule / Nodules ) Masses: ( None / Submental / Anterior Cervical / Posterior Cervical ) ( Right / Left ) Stridor: ( None / Exertion / Any breath ) ( Inspiratory / Expiratory ) ( Full phase / Early / Late ) Lymphatic Neck: ( Right / Left / None ) (anterior / post ) ( one / two / several ) ( <1cm / 1-2cm / >2cm ) (mobile / fixed) Axilla: ( Right / Left / None ) ( one / two / several ) ( <1cm / 1-2cm / >2cm ) (mobile / fixed) Groin: ( Right / Left / None ) ( one / two / several ) ( <1cm / 1-2cm / >2cm ) (mobile / fixed) Other: Supraclavicular: ( Right / Left / None ) ( one / two / several ) ( <1cm / 1-2cm / >2cm ) (mobile / fixed) Femoral: ( Right / Left / None ) ( one / two / several ) ( <1cm / 1-2cm / >2cm ) (mobile / fixed) Popliteal: ( Right / Left / None ) ( one / two / several ) ( <1cm / 1-2cm / >2cm ) (mobile / fixed) Allergy Clinic - Initial History and Physical page 5

6 Cardiovascular Heart sounds: Rate / Rhythm ( RRR / <60 / >100 / >200 / few PVC's / >10 PVC's / IR but RR / IRIR ) Sounds ( S1&S2 / +S3 / +S4 ) ( murmur 1+ / 2+ / 3+ / 4+ / LUSB / RUSB / LLSB / Apex) Lower extremity edema: ( None / Trace / <5mm / 5-10mm / >10mm ) ( Right / Left / Both ) Capillary refill: ( <1 sec / 1-2 sec / >2 sec ) ( Fingers / Toes ) JVP: ( None / at level of Angle of Louis / 4cm above / elevated ) ( while 45 deg / vertical ) Pulmonary Effort: ( Normal / Deep / Rapid / Asymmetrical ) Sounds: ( Clear ) Crackles: ( Bilateral / Right / Left ) ( Upper / Mid / Lower ) ( Anterior / Posterior ) Rhonchi: ( Bilateral / Right / Left ) ( Upper / Mid / Lower ) ( Anterior / Posterior ) Wheezes: ( Bilateral / Right / Left ) ( Upper / Mid / Lower ) ( Anterior / Posterior ) Abdominal Tenderness: ( None / Mild / Mod / Severe / with Guarding / worse on Rebound ) ( RUQ / LUQ / RLQ / LLQ ) Hernia: ( None / Umbilical / Midline / Other ) Skin Inspection: Clear ( Elbows / Knees / Legs / Arms / Face ) Patches: Dry ( Elbows / Knees / Legs / Trunk / Arms / Neck / Face ) ( Right / Left / Both ) Dark ( Elbows / Knees / Legs / Trunk / Arms / Neck / Face ) ( Right / Left / Both ) Ashy ( Elbows / Knees / Legs / Trunk / Arms / Neck / Face ) ( Right / Left / Both ) Lichenification ( Elbows / Knees / Legs / Trunk / Arms / Neck / Face ) ( Right / Left ) Papules: ( Flesh colored / Red / Dark ) ( Perifollicular / Random ) ( Upper Arms / Thighs / Both / Other ) Hives: ( Red / Pale / Red with paler center ) ( <1cm / 1-2.5cm / >2.5cm ) ( Elbows / Knees / Legs / Trunk / Arms / Neck / Face ) ( Right / Left / Both ) Palpation ( Normal / Thickened / Blanching lesions / Other ) Musculoskeletal Gait & Station: ( Normal / Antalgic R / L / Other ) Joints/Bones/Muscles: (1 or more of Head/Neck, Spine/Ribs/Pelvis, RUE, RLE, LUE, LLE) Neck ( Normal / reduced ROM / Swollen / Tender / Unstable ) Shoulders ( Normal / reduced ROM / Swollen / Tender / Unstable ) Elbows ( Normal / reduced ROM / Swollen / Tender / Unstable ) Wrists ( Normal / reduced ROM / Swollen / Tender / Unstable ) Hips ( Normal / reduced ROM / Swollen / Tender / Unstable ) Knees ( Normal / reduced ROM / Swollen / Tender / Unstable ) Ankles ( Normal / reduced ROM / Swollen / Tender / Unstable ) Digits/Nails: Clubbing ( None / Mild / Severe ) Cyanosis ( None / Mild / Severe ) MCP ( Normal / reduced ROM / Swollen / Tender / Unstable ) PIP ( Normal / reduced ROM / Swollen / Tender / Unstable ) DIP ( Normal / reduced ROM / Swollen / Tender / Unstable ) MTP ( Normal / reduced ROM / Swollen / Tender / Unstable ) PIP ( Normal / reduced ROM / Swollen / Tender / Unstable ) DIP ( Normal / reduced ROM / Swollen / Tender / Unstable ) Muscle strength & tone: ( Normal / Flaccid / Rigid / Cogwheel / Tremor ) Allergy Clinic - Initial History and Physical page 6

7 Testing ( Skin Prick / Intradermal / Patch ): Assessment Allergic: ( Conjunctivitis / Rhinitis pollen / food / animal / other ) Non-allergic (chronic) rhinitis Asthma: ( Extrinsic / Intrinsic / Chronic w/ COPD or asthmatic bronchitis / EIB / Cough var. / Unspec. ) ( unspecified / status / exacerbation ) Bronchitis: ( acute / chronic obstructive / chronic obstructive with exacerbation ) Cough Dermatitis: ( atopic / contact / food / seborrheic ) Drug Allergy Adverse Effect of Medication ( Properly used / Not as prescribed / Prescribed improperly ) GERD / LPR Headache Hiatal Hernia Otitis Media ( acute / serous ) Eustachian tube dysfunction Otitis Externa Pharyngitis Sinusitis ( acute / chronic ) URI Urticaria ( allergic or drugs, food / unspecified / with Angioedema ) Vit D deficiency Plan Allergy Clinic - Initial History and Physical page 7

East West Acupuncture & Wellness Center, Inc. Patient Intake Form

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

More information

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? 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

More information

H E A LT H H I S T O RY

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

More information

Address: City: State: Zip: Age: Birth Date: Marital Status: M S W D No. of Children. Your Employer: Occupation: Years on Job:

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.

More information

Yen Chiropractic, LLC Personal Injury Patient Intake Form Page 1

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:

More information

Premier Pain Consultants

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

More information

What are you seeking treatment for? Have you ever had acupuncture before? If so, for what condition?

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

More information

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 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 #:

More information

Divine Medicine NW Greenbrier Parkway, Suite 100 Beaverton, Oregon P F

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

More information

(PLEASE CIRCLE YES ANSWERS ONLY)

(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

More information

Phone number: When and how did your pain begin? (a date is required for Medicare and some insurance policies) Date of onset:

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

More information

INTAKE FORM ADULT. Contact Information. Date

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

More information

Holly Zapf, ND -- Whole Family Health Clinic

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:

More information

What is your stress level(1- none 10- very stressful) Occupational Personal

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:

More information

Naturopathic Intake Paperwork

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

More information

NAME: LAST FIRST MIDDLE INITIAL ADDRESS CITY STATE ZIP

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

More information

Adult Intake. (Please print clearly) Name Date. Address. Address. Home Telephone Number. Emergency contact: Name

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?

More information

(Work address): How did you hear about our clinic? Has any other family member already been a patient at the clinic?

(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:_

More information

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 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:

More information

Patient Intake Form. Name Date of birth Age Sex: Male Female

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?

More information

The following information is needed in order to better serve you. Please complete all questions.

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.

More information

c u l t i v a t e w e l l n e s s

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

More information

Non Prolotherapy Patient Intake Form

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

More information

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) 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):

More information

SOUTH TEXAS BONE & JOINT

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)

More information

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 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

More information

Date of Birth Gender. List, in order of importance, your goals for working with your physician:

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:

More information

AQI Detectives. Learning Objective: Understand the Air Quality Index and learn how to find the daily air quality. Subjects

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

More information

Infant/Children Assessment sheet Medical- Surgical unit/ ICU

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

More information

SONG OF NATURAL MEDICINE Dr. Crystal Song, NMD

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

More information

Portland Dental and Naturopathic Clinic

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

More information

Natural Healing Family Medicine

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:

More information

Family History. Patient Name: DOB: List in Order of importance what your health concerns are: 1) 2) 3) 4) 5)

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

More information

18. Which body system is needed for the exchange of oxygen and carbon dioxide? A. Respiratory B. Integumentary C. Digestive D. Urinary 19.

18. Which body system is needed for the exchange of oxygen and carbon dioxide? A. Respiratory B. Integumentary C. Digestive D. Urinary 19. 1 Student: 1. Which of the following is NOT a part of the study of anatomy? A. The structure of body parts B. Predicting the body's responses to stimuli C. Microscopic organization D. The relationship

More information

Name: Period: Chapter 1: Introduction to Human Anatomy and Physiology Study Outline

Name: Period: Chapter 1: Introduction to Human Anatomy and Physiology Study Outline Name: Period: Chapter 1: Introduction to Human Anatomy and Physiology Study Outline I. Introduction A. The interests of our earliest ancestors most likely concerned. B. Primitive people certainly suffered

More information

Dr. Roxie Strand, NMD

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:

More information

Chapter 1: Introduction to Human Anatomy and Physiology. I. Introduction A. The interests of our earliest ancestors most likely concerned

Chapter 1: Introduction to Human Anatomy and Physiology. I. Introduction A. The interests of our earliest ancestors most likely concerned Shier, Butler, and Lewis: Human Anatomy and Physiology, 11 th ed. Chapter 1: Introduction to Human Anatomy and Physiology Chapter 1: Introduction to Human Anatomy and Physiology I. Introduction A. The

More information

Adult Intake - Prenatal

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:

More information

Treatment Intake Form

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

More information

Adaptive Play and Wellness. Miela Gruber Cooley ND Registration Form (Please Print)

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

More information

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 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.

More information

Charlotte, NC (980) Roanoke, VA (540)

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?

More information

AUBURN UNIVERSITY ATHLETIC DEPARTMENT MEDICAL HISTORY QUESTIONNAIRE

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

More information

Family members living at home with the patient: Patient s school: Emergency contact: Relationship: Phone:

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

More information

Arizona Integrative Medical Solutions 4657 S. Lakeshore Dr, Ste #1 Tempe, AZ

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:

More information

Supplementary Appendix

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

More information

NEW PATIENT INTAKE. Name: Date: Address: Preferred Phone: ( ) Alternate Phone:( ) Leaving Voice Message OK: Y N Preferred method of contact:

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: / /

More information

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.   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

More information

U.S. Army Injury Surveillance Summary 2014

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

More information

1. Why Dissect. Why are frogs a good model to use when studying the digestive system (as well as other systems)?

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.

More information

1. The basic vocabulary used in anatomy is primarily derived from. A. Greek. B. Hebrew. C. Latin. D. German. E. Greek and Latin

1. The basic vocabulary used in anatomy is primarily derived from. A. Greek. B. Hebrew. C. Latin. D. German. E. Greek and Latin Page 1 of 28 1. The basic vocabulary used in anatomy is primarily derived from A. Greek B. Hebrew C. Latin D. German E. Greek and Latin 1 Student: 2. The early anatomist known as the "Prince of Physicians"

More information

Chapter 01: Organization of the Body Patton: Anatomy and Physiology, 9th Edition

Chapter 01: Organization of the Body Patton: Anatomy and Physiology, 9th Edition Chapter 01: Organization of the Body Patton: Anatomy and Physiology, 9th Edition MULTIPLE CHOICE 1. Which of the following describes anatomy? a. Using devices to investigate parameters such as heart rate

More information

Introduction Chpt 1. Study Slides

Introduction Chpt 1. Study Slides Introduction Chpt 1 Study Slides A group of molecules working together toward a common function is a: A. Cell B. Atom C. Organelle D. Tissue E. Organ ANSWER A group of molecules working together toward

More information

RENCO ELECTRONICS, INC.

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

More information

Applegate: The Anatomy and Physiology Learning System, 3 rd Edition

Applegate: The Anatomy and Physiology Learning System, 3 rd Edition Applegate: The Anatomy and Physiology Learning System, 3 rd Edition Chapter 1: Introduction to the Human Body TRUE/FALSE 1. The cell is the simplest living unit of organization within the human body. T

More information

Nombre: RED GREEN BLUE YELLOW PINK ORANGE. Color according to the instructions. Count and write the number. Celia Rodríguez Ruiz

Nombre: RED GREEN BLUE YELLOW PINK ORANGE. Color according to the instructions. Count and write the number. Celia Rodríguez Ruiz Color according to the instructions. RED BLUE ORANGE GREEN YELLOW PINK Count and write the number Read the sentences and color the picture The car is red. The cloud is blue. The dog is brown. The bird

More information

Hazard Communication & Globally Harmonized System (GHS)

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

More information

1. Medical History - This will let us know about any previous medical problems and hopefully prevent any further problems.

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.

More information

Broken Arrow Public Schools Physiology Objectives

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.

More information

PubH 7405: REGRESSION ANALYSIS MLR: BIOMEDICAL APPLICATIONS

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,

More information

Test Bank forprinciples of Anatomy and Physiology 14th Edition by Tortora

Test Bank forprinciples of Anatomy and Physiology 14th Edition by Tortora Test Bank forprinciples of Anatomy and Physiology 14th Edition by Tortora Chapter Number: 01 Question type: Multiple Choice 1) Which term describes the study of the functions of body structures? a) anatomy

More information

October 2017 Testimonies

October 2017 Testimonies October 2017 Testimonies In Florida: Prayed for a woman with right hip pain. Checked her legs and Jesus grew one out about one-half inch. Commanded the pain to go and for complete healing of the hip flexor.

More information

16. Why are many anatomical terms based on Greek and Latin roots? A. because they are easy to spell B. because many terms are based on the names of

16. Why are many anatomical terms based on Greek and Latin roots? A. because they are easy to spell B. because many terms are based on the names of 1 Student: 1. Which of the following is NOT true? A. Anatomy is the study of the structure of the body. B. Gross anatomy is the study of tissues and cells. C. Comparative anatomy is the study of more than

More information

1. Anatomy is. 2. Which subdivision of anatomy involves the study of organs that function together?

1. Anatomy is. 2. Which subdivision of anatomy involves the study of organs that function together? 1 of 19 1 Student: 1. Anatomy is A. the study of function. B. a branch of physiology. C. the study of structure. D. the study of living organisms. E. the study of homeostasis. 2. Which subdivision of anatomy

More information

In a small time t: BMR; BMR BMR BMR BMR BMR The brain constitutes only 2.5% of body weight, but is responsible for 20% of the BMR (dreams). It requires a fair amount of oxygen consumption. Weight

More information

New Immigrant Survey Section D - Health

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

More information

ANATOMY AND PHYSIOLOGY Revised 11/2010

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,

More information

3) Using your fingers to find your pulse on your wrist is an example of

3) Using your fingers to find your pulse on your wrist is an example of Package Title: Testbank Course Title: PAP13 Chapter Number: 01 Question type: Multiple Choice 1) This is the study of the functions of body structures. a) anatomy b) physiology c) endocrinology d) histology

More information

NUTRITIONAL PATIENT QUESTIONAIRE

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)

More information

II. Anatomy and Physiology A. Anatomy is. B. Physiology is.

II. Anatomy and Physiology A. Anatomy is. B. Physiology is. Shier, Butler, and Lewis: Human Anatomy and Physiology, 13 th ed. Chapter 1: Introduction to Human Anatomy and Physiology Chapter 1: Introduction to Human Anatomy and Physiology I. Introduction A. The

More information

Online supplement. Absolute Value of Lung Function (FEV 1 or FVC) Explains the Sex Difference in. Breathlessness in the General Population

Online supplement. Absolute Value of Lung Function (FEV 1 or FVC) Explains the Sex Difference in. Breathlessness in the General Population Online supplement Absolute Value of Lung Function (FEV 1 or FVC) Explains the Sex Difference in Breathlessness in the General Population Table S1. Comparison between patients who were excluded or included

More information

HEALTH HISTORY FORM. Patient Name: Birth Date: / / Supportive relationship(s)? Yes No Spiritual Practice? Yes No If yes,

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

More information

AT THE DOCTOR S TRANSCRIPT & NOTES

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.

More information

WORKERS COMPENSATION HISTORY

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

More information

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. 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

More information

IKDC DEMOGRAPHIC FORM

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

More information

Accident/Incident Report and Investigation Form

Accident/Incident Report and Investigation Form Accident/Incident Report and Investigation Form EMPLOYEE INFORMATION Name: First MI Last Social Security#: Dept.: Job Title: Full Time Part Time Student Worker Other ACCIDENT/INCIDENT INFORMATION Date

More information

Supplementary webappendix

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

More information

NUTRITIONAL PATIENT QUESTIONAIRE

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)

More information

CASE REPORT FORM (April 2012)

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

More information

Heat and Cold in Medicine

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;

More information

HUMAN BODY THE SKELETAL AND MUSCULAR SYSTEMS REM 653 A TEACHING RESOURCE FROM...

HUMAN BODY THE SKELETAL AND MUSCULAR SYSTEMS REM 653 A TEACHING RESOURCE FROM... THE HUMAN BODY SKELETAL AND MUSCULAR SYSTEMS A TEACHING RESOURCE FROM... REM 653 AUTHOR Melba Callender 1987, 2001 Copyright by Remedia Publications, Inc. All Rights Reserved. Printed in the U.S.A. The

More information

Toxic Algae and Cyanobacteria in Recreational Waters. Rang Cho Miriam Moritz

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

More information

PATIENT PROFILE PERSONAL INFORMATION

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

More information

Science Department. 1 st Primary. First & Second Term Booklet

Science Department. 1 st Primary. First & Second Term Booklet Science Department 1 st Primary First & Second Term Booklet 1 Unit 1 Living and Non-living organisms Kindly watch these videos: http://youtube.com/watch?v=bn0vwkqorhk https://www.youtube.com/watch?v=p51fipo2_kq

More information

Electromagnetic Radiation (EMR)

Electromagnetic Radiation (EMR) Electromagnetic Radiation (EMR) It is kind of energy with wave character ( exactly as sea waves ) that can be characterized by : Wavelength ( ) : The distance between two identical points on the wave.

More information

Chapter 1. The Human Organism 1-1

Chapter 1. The Human Organism 1-1 Chapter 1 The Human Organism 1-1 Overview of Anatomy and Physiology Anatomy: Scientific discipline that investigates the body s structure Physiology: Scientific investigation of the processes or functions

More information

Childhood Nephrotic Syndrome

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

More information

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 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

More information

Chapter 6 General Anatomy and Physiology

Chapter 6 General Anatomy and Physiology Chapter 6 General Anatomy and Physiology MULTIPLE CHOICE 1. The study of the human body structures that can be seen with the naked eye is. a. anatomy c. biology b. physiology d. pathology Anatomy is the

More information

Supplementary Online Content

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

More information

Downloaded from

Downloaded from INTERNATIONAL INDIAN SCHOOL, RIYADH SCIENCE WORKSHEET SA2 STD. V 2012-13 L-6 Nervous System (FA3 + SA2) I Fill in the blanks:- 1. The brain gets its signals from various parts of the body through the 2.

More information

Unit 2 Benchmark Review. Disease Review:

Unit 2 Benchmark Review. Disease Review: Match the term with the definition: Unit 2 Benchmark Review Disease Review: 1. Caused by tiny organisms called pathogens B 2. This is responsible for distinguishing between the different kinds of pathogens

More information

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 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

More information

Arizona Integrative Medical Solutions 4657 S. Lakeshore Dr, Ste #1 Tempe, AZ

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

More information

IMPROVING THE OUTCOMES OF BREAST RADIATION THERAPY: THE PRONE POSITION. Kaylyn Olson

IMPROVING THE OUTCOMES OF BREAST RADIATION THERAPY: THE PRONE POSITION. Kaylyn Olson IMPROVING THE OUTCOMES OF BREAST RADIATION THERAPY: THE PRONE POSITION Kaylyn Olson BACKGROUND Over 230,000 women will be diagnosed with breast cancer this year and approximately half of these women will

More information

BIOLOGY 5090/21 Paper 2 Theory October/November 2016 MARK SCHEME Maximum Mark: 80. Published

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

More information

CUMBERLAND COUNTY SCHOOL DISTRICT BENCHMARK ASSESSMENT CURRICULUM PACING GUIDE Subject: Anatomy & Physiology Grade: 11-12

CUMBERLAND COUNTY SCHOOL DISTRICT BENCHMARK ASSESSMENT CURRICULUM PACING GUIDE Subject: Anatomy & Physiology Grade: 11-12 Benchmark Assessment 1 Instructional Timeline: 8 weeks Topic(s): Introduction, Tissues, Integumentary System Describe the major components and functions of physiological systems, including skeletal, muscle,

More information