Health History 1) Are you in good health? Y N Digitalis, Inderal, Nitroglycerin or other heart Y N 2) Has there been any change in drug? your general health in the past year? Y N Have you ever been advised Not to take a 3) Date of last physical exam:____________ medication? Y N 4) Are you under a physician’s care for Are you taking or have you ever taken a particular problem? Y N Bisphosphonates for osteoporosis, multiple 5) Have you ever had any serious myeloma, or other cancers(Reclast, Fosomax, Illnesses, operations, or hospitalizations? Y N Actonel, Bonevia, Aredia, Zometa)? Y N If yes, describe:_____________________________ List any and all medications you are currently taking, Including all over the counter medications, diet drugs, __________________________________________ Vitamins, and minerals:_____________________________ ____________________________________________ Do you have or have you ever had: _________________________________________ _____________________________________________ Rheumatic Fever or Rheumatic Heart Disease? Y N _____________________________________________ ______________________________________________ Congenital Heart Disease Y N Cardiovascular Disease(Heart Attack, Heart Y N Are you allergic to or have you had an adverse Trouble, Heart Murmur, Coronary Artery Disease, reaction to: Angina, High Blood Pressure, Stroke, Palpitations, Health Surgery, Pacemaker)? Local Anesthesia (Novocain, etc)? Y N Penicil in or other antibiotics? Y N Lung Disease(Asthma, Emphysema, COPD, Chronic Sedatives or Barbiturates? Y N Cough, Bronchitis, Pneumonia, Tuberculosis, Aspirin or Ibuprofen? Y N Shortness of Breath, Chest Pain) Y N Codeine or other pain killers? Y N Latex or other Rubber Products? Y N Seizures, Convulsions, Epilepsy, Fainting, or Y N Metal of any kind? Y N Dizziness? Chemicals or jewelry (rash or sensitivity) Y N Food Products? Y N Bleeding Disorder, Anemia, Bleeding Tendency, Other allergies or reactions? If yes, please list Y N Blood Transfusion? Do you bruise easily? Y N ____________________________________________ _____________________________________________ Liver Disease(Jaundice, Hepatitis) Y N Kidney Disease Y N Do you smoke or chew tobacco? Y N Diabetes Y N How much per day?____________________________ Thyroid Disease(Goiter) Y N Is there a past history of Alcohol or Chemical dependency Arthritis Y N or Emotional Disorder the may affect the care we provide Stomach Ulcers or Colitis Y N you? Y N Glaucoma Y N Osteoporosis Y N Have you had any serious problems associated Implants placed anywhere in your body with any previous dental treatment? Y N (Heart Valve, Pacemaker, Hip or Knee)? Y N Have you or an immediate family member had any Radiation (X-Ray)treatment for cancer? Y N problem associated with intravenous anesthesia? Y N Clicking or popping of jaw joint, pain near ear, Do you have any other disease, condition, or difficulty opening mouth, grind or clench teeth? Y N problem not listed above you think the doctor should know about? Y N Sinus or Nasal problems? Y N Any disease, drug or transplant operation that Do you wish to talk to the Doctor privately about has depressed your immune system? Y N anything? Y N Are you using any of the following: Have you ever had a bone density scan? Y N For Women Only: Antibiotics? Y N Are you pregnant, or is there any chance you Anticoagulants (blood thinners) Y N might be pregnant? Y N Aspirin or drugs such as Motrin, Aleve, or Are you nursing? Y N Tylenol? Y NIf you are using oral contraceptives, it is important that High Blood Pressure medications? Y N you understand that antibiotics (and some other Steroids(Cortisone, Prednisone, Etc) Y N medications) may interfere with the effectiveness or oral Tranquilizers? Y Ncontraceptives. Therefore, you will need to use other Insulin or Oral Anti-Diabetic drugs? Y N forms of birth control for one complete cycle of birth control pills, after the course of antibiotics or other meds Is complete. Please consult with your physician for further guidance. ______________________________________________________ Patient Signature Date
Indian Journal of Weed Science 45 (4): 247–249, 2013 Distribution of weed flora of greengram and blackgram in Haryana S.S. Punia*, V.S. Hooda, Anil Duhan, Dharambir Yadav and Amarjeet Department of Agronomy, CCS Haryana Agricultural Univesrity, Hisar125 004 Received: 12 October 2013; Revised: 23 December 2013 ABSTRACT To study the floristic composition of weeds in greengram, 50
Neurotherapeutics: The Journal of the American Society for Experimental NeuroTherapeutics Diana Conte Camerino, Domenico Tricarico, and Jean-François Desaphy Pharmacology Division, Department of Pharmacobiology, School of Pharmacy, University of Bari, Bari, Italy Summary: Because ion channels are involved in many cellular tions have demonstrated that channel mutations can either in-proces