Para compra cialis puede ser visto como un desafío. Aumenta Smomenta, y todos los que se poco a poco abrumado, como es lógico, cada vez más hombres están diagnosticados con disfunción eréctil.

Why are you here today

Robert V. Kolbusz, M.D.
Why are you here today?
(If you are not here for Acne or a Rash, fill out as many questions as you can from this Questionnaire.) Please DO NOT MARK ON ANY
UNUSED QUESTIONNAIRES
3825 Highland • Suite 5C • Downers Grove, IL 60515 • 630-964-2000 Fax 630-964-2033 Robert V. Kolbusz, M.D.
ACNE QUESTIONNAIRE

PATIENT:________________________________
DATE:_____________________
Are you currently treating your acne with over-the-counter products? ________________________ _________________________ _________________________ Have you used any of the following medications? Dates treated: _____________ _____________ _____________ _____________ WARNING TO FEMALE PATIENTS: Many acne medications CANNOT be used in women during pregnancy and breastfeeding, nor if you are planning pregnancy in the near future. Are you currently: Pregnant If you are sexually active, do you use birth control? Birth Control Pill
SIGNATURE
:___________________________
3825 Highland Avenue • Suite 5C • Downers Grove, IL 60515 • 630-964-2000 Fax 630-964-2033 Robert V. Kolbusz, M.D.
RASH QUESTIONNAIRE
PATIENT:________________________________ DATE:____________________ AGE: ________________ DURATION OF RASH: ______YEARS ______MONTHS ______DAYS 1. IN WHICH LOCATION DID YOUR RASH BEGIN:______________________________________ AND THEN WHERE DID IT SPREAD TO:____________________________________________ ARE YOU CURRENTLY TREATING OR RECEIVED PAST TREATMENT? ‰ YES ‰ NO DO YOU OR YOUR FAMILY MEMBER(S) HAVE A HISTORY OF: CIRCLE M FOR YOURSELF OR LIST FAMILY MEMBER(S) ‰ YES ‰ NO ________________________________________________ ‰ YES ‰ NO ________________________________________________ ‰ YES ‰ NO ________________________________________________ ‰ YES ‰ NO ________________________________________________ ‰ YES ‰ NO ________________________________________________ ‰ YES ‰ NO ________________________________________________ ‰ YES ‰ NO ________________________________________________ HOW OFTEN DO YOU BATHE? ___________________________________________________ WHICH BRANDS OF SOAP(S) DO YOU USE? _______________________________________ DO YOU BATHE WITH WARM OR HOT WATER? ____________________________________ DO YOU USE MOISTURIZERS ROUTINELY? ‰ YES WHICH BRANDS? ______________________________________________________________ _____________________________________________________________________________ SIGNATURE: _______________________________
3825 Highland Avenue • Suite 5C • Downers Grove, IL 60515 • 630-964-2000 Fax 630-964-2033 Robert V. Kolbusz, M.D.
SKIN LESION QUESTIONNAIRE
PATIENT: _________________________________ DATE: ___________________ PLEASE MARK THE SITE OF YOUR LESION(S). DURATION OF LESION(S):____________YEARS____________MONTHS____________WEEKS 1. WHAT HAS BROUGHT THE LESION TO YOUR ATTENTION NOW? (CIRCLE)
INTERFERES WITH _____________________ CUTS WITH SHAVING OTHER_________________________________________ 2. HAS THE LESION BEEN PREVIOUSLY TREATED?
‰ YES ‰ NO
IF SO, WHEN WAS IT TREATED? DATE: __________________________
3. DO YOU HAVE A FAMILY HISTORY OF SKIN CANCER?: (CHECK ALL THAT APPLY)

IF YES WHICH FAMILY MEMBER? ____________________
‰ SQUAMOUS CELL CARCINOMA ‰ DYSPLASTIC NEVUS 4. DO YOU HAVE A PERSONAL HISTORY OF SKIN CANCER? ‰ YES ‰ NO
IF YES, WHICH TYPE?
‰ SQUAMOUS CELL CARCINOMA ‰ DYSPLASTIC NEVUS SIGNATURE: __________________________
3825 Highland Avenue • Suite 5C • Downers Grove, IL 60515 • 630-964-2000 Fax 630-964-2033

Source: http://www.centerderm.com/forms/questions.pdf

Lyrica smith res app.qxd

Worship in Jerusalem 2006 Conference & Tour RESERVATION APPLICATION Please complete this entire form and return, together with your $500 per person tour deposit to: International Church for All Nations, C/O Apostle Lyrica Smith. Deposits can be paid by check or credit card. Be sure to write your name(s) exactly as on your passport, so that your airline ticket and alldocuments will co

Microsoft word - treatmentsforminordiscomobgynv4.doc

Treatments for Minor Discomforts Colds, Congestion, Cough, Mucinex DM, Coricidin D, Neo-Synephrine Nose Drops (not nose spray), and Seasonal Allergies: Saline drops, Tylenol Cold/ Sinus/ Allergy, Sudafed, Robitussin (plain) PE, Dimetapp Extentabs, Dimetapp Elixir, Chlor-Trimeton 4mg, Plain Benadryl, Claritin, Actifed, Non-medicated cough drops. Sore Throat: Chloraseptic Spray, Cepa

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