Please list all medications (even over-the-counter medications and herbal supplements). Note all strength and dosages. Bring this along with your visit.
Do you know of any blood relative who has or had: (Circle and Give Relationship) Stroke ______________ Tuberculosis __________ Blood Disease _________ Arthritis _________ if diagnosed by a doctor, is it __________ Rheumatoid Arthritis ____________Osteoarthritis ________ High blood pressure _______________ Asthma ________________ Bleeding Tendency ____________ Heart Attack _______________ Epilepsy _________ Cancer _____________ What Kind of Cancer _____________ Diabetes _________ Kidney Disease _____________ Gout ________ Problems with back __________ Osteoporosis _______
Personal History
Present Occupation Are you working Now? Yes No Full time Part Time Past Occupation Unable to work since: Sports or hobbies Military service Have you ever smoked yes No Cigarettes Pipe Cigars How many per day? For how many years did you smoke ____________ How long ago did you quit? Do you regularly drink alcohol __________ Occasionally ________ Is alcohol a problem for you? Where have you lived? (geographically) Describe your current residence Apartment Home How many levels Where is your bedroom/bathroom in the home Which of the following do you use? cane walker electric cart standard wheelchair toilet riser What is the most difficult thing for you to do at home?
Past History
Record the diseases, surgeries and injuries you have had
Medications
Are you presently taking any of the following medications?
Name Any Drugs that you are ALLERGIC to:
Name of Drug Describe Reaction Describe any other allergies you have How is your appetite? Good Fair Poor Have you gained weight lost weight ______ lbs in _____ months? Are you on a special diet? Yes No What kind?
Patient Name DOB Medical Record # Date When did you first notice your symptoms? Do you have morning stiffness? For how long? Hours Do you become unusually fatigued in the afternoon or evening? Yes No At what time ____________ Does sunlight bother you or cause a rash? Yes No Do your hands get blue or white with cold? Yes No Have you had hair loss? Yes No Do you have significantly dry eyes? Yes No Mouth? Yes No Please list the joints which have been involved List names of physicians, podiatrists or chiropractors you have seen for arthritis and the approximate date of these evaluations. Have you taken any of the following drugs: (Circle Ones you have taken)
Aspirin (Anacin, Ascriptin, Bufferin, Ecotrin)
Codeine, Vicodin, (Hydrocodone), Lortab, Lorcet
Disalcid, Salsalate, Monogesic, Trilisate
Estrogens (Premarin, Estrace, Ogen, Evista)
Muscle Relaxants (soma, Norflex, Flexeril, Paraton, Cyclobenzaprine)
Voltaven (Diclofenac), Cataflam, Arthrotec
Zostrix Cream (Capsaicin), Dolorac, Mobisyl
Joint injections _______________ Which joints? __________________ Have you had physical therapy Yes No Specifically for arthritis? Yes No When ____________________ Did it help? ______________________
On a Scale of 1 to 10 How Would you Rate Your Pain None | _____|_____|_____|_____|_____|_____|_____|_____|_____| Most Severe 1 2 3 4 5 6 7 8 9 10 PLEASE Do Not Write in the Space Below Have you had fever or chills recently? Do you have frequent headaches? Have you ever had a convulsion, fit or epilepsy? Have you had a rash or other skin problem? Have you had red or inflamed eyes? Have you had pain or ringing in your ears? Do you have trouble swallowing? Have you ever had shortness of breath? Do you have a chronic cough? Have you ever had chest pain or tightness in your chest? Have you had a heart attack? (Year ____) Do you frequently have stomach upsets? Have you had any recent changes in your bowel habits? Have you ever had an ulcer? (Year _____) Have you had intestinal bleeding or black or tarry stools? Have you had recent frequency or burning with urination? Do you have to get up frequently at night to urinate? (how many times) Have you ever passed a kidney stone? (Year Are you sensitive to cold exposure than most Have you been nervous or depressed? To be answered by WOMEN only: Has there been a change in frequency or amount of your menstrual flow Date of last period Date of last pap smear (cancer test? Dexa or Yes No osteoporosis If yes, date ________ screening Where_______ Number of Pregnancies? Number of Children born alive? Cerner Patient Registration Information Sheet Patient Information Physician ____________ Appt. Date ___________ Appt. Time _________ Patient Name _______________________________ Suffix (circle one ) II III Jr. Sr. Last First MI Preferred Name _____________________ Maiden Name __________________ Title (Circle one) Captain/Colonel/Doctor/Father/Lieutenant/Major/Reverend/Sister Gender _____ Birth date ________ SS# __________________________ (month/date/year) Marital Status (circle one) divorced/ legally separated/ married / single/widowed Billing Address __________________________________________________ City _____________ State __________ Zip ______________ Home Phone __________ Work Phone _________ Work extension _____ Resides at Address _________________________________________ City ______________ State _________ Zip _________________ Employment status (circle one) Active Military Duty/ full time/ not employed/ part time/ retired/ self employed/ unknown Employer _________________________________________________ (If self-employed please state name of Company/or Occupation) Employer address ____________________________________________ EMERGENCY CONTACT Relationship to Patient ______________ Name _____________________ Home Phone ________________ Work Phone ____________ Work Extension _____ Primary Care MD________________ Please indicate (X) if no Primary Care MD_____ Referring MD________________ Please indicate (X) if no Primary Care MD ______ Special Needs (ex: patient in wheelchair, hearing impaired) _____________
RESPONSIBLE BILLING PARTY Relationship to Patient ________________ Name ___________________ Gender _____ Birth date _______ SS# _____________________ Address _______________ City ___________ State ______ Zip ______ Home Phone _____________ Work Phone __________ Work Extension ________ Employment status (circle one) Active Military Duty/ full time/ not employed/ part time/ retired/ self employed/ unknown Employer _________________________________________________ (If self-employed please state name of Company/or Occupation) Employer address ____________________________________________ First Insurance Information Insured’s Relationship to Patient ____________ Name _______________ Gender _____ Birth date _______ SS# _____________________ Address _______________ City ___________ State ______ Zip ______ Home Phone _____________ Work Phone __________ Work Extension ________ Employment status (circle one) Active Military Duty/ full time/ not employed/ part time/ retired/ self employed/ unknown Employer _________________________________________________ (If self-employed please state name of Company/or Occupation) Employer ____________________________________________ Insurance Company Name ___________________________________ Group Name _____________ Group # ____________ Effective date _________ Insured’s Policy/Certificate #______________ Patient’s Policy/Certificate # _______ ________________________________________________________________________ Second Insurance Information Insured’s Relationship to Patient ____________ Name _______________ Gender _____ Birth date _______ SS# _____________________ Address _______________ City ___________ State ______ Zip ______ Home Phone _____________ Work Phone __________ Work Extension ________ Employment status (circle one) Active Military Duty/ full time/ not employed/ part time/ retired/ self employed/ unknown Employer _________________________________________________ (If self-employed please state name of Company/or Occupation) Employer ____________________________________________ Insurance Company Name ___________________________________ Group Name _____________ Group # ____________ Effective date _________ Insured’s Policy/Certificate #______________ Patient’s Policy/Certificate # _______
A Review of some meta-analytic comparisons of pharmacological interventions for prevention of cardiovascular disease in Type 2 diabetes A.G. Shannon Warrane College, The University of New South Wales, & KvB Institute of Technology, North Sydney, NSW 2060, Australia This paper was written to mark the retirement of Professor Soonki Kim, friend and colleague Introduction
Research Article www.ijcps.com International Journal of Chemical and Pharmaceutical Sciences Formulation and Evaluation of oral controlled release matrix tablets of Paroxetine Mahendar R *, Sambashiva D, Valmiki R and Ramakrisha K MRR College of B. Pharmacy, Nadergul v