Pharmacie sans ordonnance livraison rapide 24h: acheter viagra en ligne en France.

Microsoft word - patient intake form2.doc

6410 Rockledge Drive, Suite 110, Bethesda, MD, 20817 (O) 301.530.7303 (F) 301.530.7312
2112 F Street, NW, Suite 802A, Washington, DC, 20037 (O) 202.775.7246 (F) 202.775.2345
NAME: ____________________________________________ DATE: ____________

Home Phone: ____________________ Work Phone: _______________________
Cell Phone: ______________________ Who to call in case of emergency: ___________
Name of the doctor who has referred you: _____________________________________
Names of doctors who should get this report: ___________________________________

REASON FOR VISIT:
___________________________________________________
The worst area(s) of pain: __________________________________________________
Please mark the areas of pain

Please rate your average daily pain
: from 0 (no pain) to 10 (worst possible pain): /10

Length of time that you have had this pain in this area
: ________________________

Has something or an event started your pain?
YES NO If so what event?
________________________________________________________________________
Circle factors that aggravate your pain? None Standing Exercising Walking
Bending Straining Lifting Stress Weather changes Medications Repetitive motions
Sitting Head movement Mood swings Light touch Deep breathing Coughing Bearing
down Lying down Rolling in bed Other ______________________________________

Circle factors that help your pain:
Nothing Resting Walking Standing Sitting
Moving Physical therapy Massage Heat/Ice packs Medication Lying down
Changing Positions Other__________________________________________________
Circle all characteristics of your pain: Constant Intermittent Burning Sharp
Shooting Aching Throbbing Tingling Numbness Other _________________________
Circle prior treatments:
Anti-inflammatory medications: (example Ibuprofen), Celebrex, Medrol dose pack
Narcotics: Ultram (tramadol), Percocet, Oxycodone, Oxycontin, Vicoden, Hydrocodone,
Morphine, Methadone, Dilaudid, Hydromorphone, Duragesic, Actiq
Antidepressants: Elavil (Amitriptylline), Pamelor (nortriptylline), Trazodone,
Desipramine, Cymbalta
Antiseizure medication: Neurontin, Trileptal, Topamax, Gabitril, Lyrica
Acupuncture, Magnets, Massage, Chiropractic manipulation, Herbs, Physical therapy
Nerve Blocks , Epidural injections, Facet blocks , other ___________________________
ALLERGIES: __________________________________________________________
ALL CURRENT MEDICATIONS YOU ARE TAKING: ______________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
PAST AND PRESENT MEDICAL ISSUES/DISEASES: ______________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________

PAST SURGERIES
: _____________________________________________________
________________________________________________________________________
________________________________________________________________________


FAMILY HISTORY:


SOCIAL HISTORY: Circle all that applies to you.
Single Married Divorced Separated Widowed Partnered
Do you have children? Yes No How many? ___________________________________
Do you work? Yes No If so, describe please_________________________________
Do you Smoke? Yes No How much? _______________________________________
Do you drink? Yes No How much? _______________________________________
Do you use illicit drugs? Yes No How much? _______________________________
Have you ever been addicted to nicotine, alcohol, or illicit drugs? If so, Please explain
________________________________________________________________________
Are you involved in any unsettled legal issues involving your symptoms? Yes No
If so, please explain:
________________________________________________________________________
________________________________________________________________________

GENERAL HEATH QUESTIONS
: Have you had any of the following in the past 2
weeks? (Circle all that applies to you)
Fevers Chills Night sweat Unexplained weight loss Eye problems Ear problems
Heart problems Lung problems Stomach problems Bladder /kidney problems Skin
problems Neurological problems Psychological issues Thyroid problems Diabetes
Bleeding problems
Please explain any of the above:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________

Source: http://webmdpain.com/PMI_new_patient_form.pdf

Microsoft word - n-065-26.doc

Sonnenschein Lithium GmbH Industriestrasse 22 D-63654 Büdingen Technical Notice Safety data sheet 1. Identification 1.1 Product Name: 1.2 Company: 1.3 Emergency Telephone Number: 2. Composition/Information on Ingredients R 14/15 Reacts violently with water liberating extremely flammable gases Important Note: The material in this section may only rep

Afterpain.p65

Guillain-Barré Syndrome Support Group After GBS — Pain This series of guides is produced by the Guillain-Barré Syndrome Support Group. We are aregistered charity that supports those affected by the Guillain-Barré syndrome (GBS) and relatedconditions in the United Kingdom and the Republic of Ireland. The related conditions includechronic inflammatory demyelinating polyradiculoneuropath

Copyright © 2010-2014 Sedative Dosing Pdf