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Microsoft word - patient questionnaire.doc

MEDICAL HISTORY QUESTIONNAIRE
Name: ______________________________________________________ Age: ______________________
Chief Complaint: ___________________________________________________________________________________

FAMILY HISTORY:
Give age if living or age and cause of death.
Father _____________________________________ Mother _________________________________ Siblings ____________________________________ Children ________________________________ Is there an immediate family history (someone related by blood) of any of the fol owing: ALLERGIES AND SENSITIVITIES: Indicate which, if any are present:
MEDICATIONS: List al medications you currently take:
Sedatives, Sleeping Pil s, Tranquilizers Digitalis, Nitroglycerine, Cardiac Drugs Appetite Suppressants- including Phen-Fen SOCIAL HISTORY (circle one)
Tobacco:

SURGICAL HISTORY:
List al prior surgeries, as wel as cosmetic (including chemical peels).
Type: ________________________
Date: _________________________ Surgeon: ________________________ Date: _________________________ Surgeon: ________________________ Date: _________________________ Surgeon: ________________________ Did you experience any problems or complications during or fol owing above procedures? No________ Please explain_____________________________________________________ _________________________________________________________________________________________________
PAST MEDICAL HISTORY: List any prior hospitalizations below (e.g. accidents, surgeries, etc.).
Purpose: ______________________ Date: _________________________ Physician: _______________________
Purpose: ______________________ Date: _________________________ Physician: _______________________ Purpose: ______________________ Date: _________________________ Physician: _______________________ Have you recently been under the care of a physician for any reason?
If yes, please explain: ______________________________________________________________________________
_________________________________________________________________________________________________
Name, Address & Telephone Number of Physician: _______________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
REVIEW OF SYSTEMS: Check if any apply:

Is there any history not noted above of which the doctor should be aware? If yes, please explain: ______________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ This information is correct and true to the best of my knowledge. Patient Signature: ______________________________________________ Parent/Guardian Signature: _______________________________________

Source: http://www.drgrover.com/forms/medical_history.pdf

Microsoft word - genee past winners chronology.doc

Past Winners of the Prestigious Genée International Ballet Competition Many past winners of the Genée International Ballet Competition have become professional dancers with companies all over the world. For many, their careers have been long and varied as directors, artistic directors, ballet masters, teachers, administrators, dance critics, and TV producers/directors. Chronology:

Register2003_endg.qxd

medien recht Register 2003 Zeitschrift für Medien- und KommunikationsrechtRedaktion und Verlag: 1040 Wien, Danhausergasse 6, Tel. 01/505 27 66, Fax 505 27 66-15E-Mail: verlag@medien-recht.com http://www.medien-recht.com Beiträge Abgabenrecht – „MA 2412“ und der Schutz von characters (Thomas Höhne) ,– Werbeabgabe: Erlass zur Besteuerung der Prospektwerbung– Neu geboren

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