Para compra levitra 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.

Kentucky ear, nose and throat patient health history

Kentucky Ear, Nose and Throat Patient Health History
Name:_______________________________ Date of Birth:__________ Date:_________
This section for office use only
Vital Signs: Height:___ft____in Weight:_______ Temp:_______ Pulse:_______ BP ____/____(Adults)

What is the main reason you are being seen at KY Ear, Nose and Throat
Have you or any family member ever been seen at our office before? Yes Name:_________________________

Have you/the patient been diagnosed with any of the following? Check all that apply. 2. TOBACCO USE: □ None □ Quit (date) __________ Stil use: □ Cigarettes □ Smokeless/Chew □ Cigars □ Pipe
Check the amount of tobacco you use(d) each day.
How many years did/have you smoked? ____________ 3. Are you/the patient exposed to second hand smoke? □ Yes □ No
4. ALCOHOL USE: □ None (A drink is 1 shot of liquor, 1 glass of wine, or 1 bottle/can of beer.)
□ Less than 1 drink/month □ 1-15 drinks/month □ 4-14 drinks/week □ More than 2 drinks/day
5. Will you/the patient accept transfusion of blood products if necessary?
6. Does the patient attend daycare? □ Yes □ No
7. HOME LIVING SITUATION: Check all that apply.
□ Alone
□ With mother □ With father □ With spouse □ With siblings □ With children □ In nursing home □ In assisted living □ In foster care □ With significant other 8. FAMILY HISTORY: Check which family members have had the following:


9. REVIEW OF SYSTEMS: Check any symptoms that you /the patient have now or have recently had.
10. ALLERGIES: Are you allergic to any of the following? Check all that apply.
□ Latex
What happens when you take this medication? □ Itching □ Rash □ Nausea □ Shortness of Breath □ Anaphylaxis □ Itching □ Rash □ Nausea □ Shortness of Breath □ Anaphylaxis □ Itching □ Rash □ Nausea □ Shortness of Breath □ Anaphylaxis □ Itching □ Rash □ Nausea □ Shortness of Breath □ Anaphylaxis 12. CURRENT MEDICATIONS: □ NONE
10 Nasal Spray: □ None □ Astelin □ Flonase □ Nasonex □ Nasocort AQ □ Rhinocort Aqua □ Afrin
13. PAST SURGICAL HISTORY: (Include all operations that you have had)
14. OCCUPATION:________________________________________ □ Retired
Your pharmacy is? _________________________
Notes: ______________________________________ Address: _________________________________ ____________________________________________ Phone number: ____________________________ ____________________________________________ This form was completed by: ___________________________________________ Date: ______________________ Relationship to patient: □ Self □ Mother □ Father □ Daughter □ Son □ Other (specify)______________________


Microsoft word - news100 web.doc

Go For Research & Development Grants 100 ISSUES by Paul St. Clair, F.C.A., Peter Small, B. Bus, F.C.A., and Avinash Lakhan, BFA/LLB. C.A We are proud to provide you with the 100th Edition of • The Australian dollar was a regulated currency (it was our Client Newsletter. Our first newsletter was sent to clients in April, 1981. The newsletter has always been Our February, 1984 le

Kost e n - ba t e n a n a lyse bij in t e gr a le ge bie dsv e r k e n n in ge n Sum m ary The m et hod used in t he decision- m aking process for t ransport infrast ruct ure t o syst em at ically ident ify social im pact s ( a social cost - benefit analysis as described in t he guidance docum ent on infrast ruct ure effect s ‘Overzicht Effect en I nfrast ruct uur’ – OEI ) is in pri

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