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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:_________________________

1. PAST AND CURRENT MEDICAL HISTORY:
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:

Name:____________________________________________

9. REVIEW OF SYSTEMS: Check any symptoms that you /the patient have now or have recently had.
Fever
10. ALLERGIES: Are you allergic to any of the following? Check all that apply.
□ Latex
11. DRUG ALLERGIES: □ NONE
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)______________________

Source: http://www.kyent.com/Media/54/KYENT_Medical_History.pdf