TOBACCO (smoke, chew, dip) ______________________ __________________________ ALCOHOL (beer, wine, hard liquor) ____________________ __________________________ CAFFEINE (colas, coffee, tea) ________________________ ___________________________ IMPAIRMENTS: Check if you have any of the following: Physical Impairment ____________ Visual Impairment ______________ Hearing Impairment __________ EXERCISE: Do you exercise regularly? ___Y ____N If Yes: Please note exercise & how often: STRESS MANAGEMENT: Do you practice stress management techniques? ___Y ____N If Yes, pls describe: DIET: Describe your typical daily food intake: Breakfast: Lunch: Supper: Any Snacks/other: 3) DOCTOR INFORMATION: Please list each Dr. from whom you seek care with address & phone number. 4) ALLERGIES: please check all that apply: ___None Known __penicillin __codeine
Note allergic reaction: ________________________________________________________________ ___________________________________________________________________________________ 5) OVER THE COUNTER (OTC) ISSUES: Please check all products used regular or occasionally. __pain reliever __ibuprofen (eg. Motrin)
__other: ___________________________________ __Nutritional/Natural Supplements: Pls identify and list products you are using: -herbs, vitamins, minerals, supplements, enzymes, others 6) MEDICAL CONDITIONS/DISEASES. Please check all that apply to you.
7) PRESCRIPTION MEDICATION: List all prescription medication you are using (include physician samples)
NAME__________________________________________________________DATE_________________ Circle the number that best describes your pain, 0 is NO PAIN and 10 is WORST IMAGINABLE PAIN.
Circle the number that best describes your pain at its worst during the last month.
Circle the number that best describes your pain at its least during the last month.
Circle the number that best describes your pain on average during the last month.
Circle the number that best describes your pain as it is right now.
Impresso Especial JORNAL DO Informativo do Instituto de Previdência e Assistência dos Servidores do Município de Vitória DIA DO IDOSO 27 de setembro - Nesta I Encontro de Aposentados (as) e Pensionistas O IPAMV, através da Seção de Serviço Social, promoverá no dia 21 de setembro tribuição previdênciaria e 2ª via de (quinta-feira), às 14 horas, no se
National & Oregon Immigration Rights Resources Compiled by Ecumenical Ministries of Oregon Sections: I. National Immigration Information and Rights Sites II. Religious Groups with National Immigration Legislation Information III. State Immigration Rights and Legislation Information IV. Religious Statements and Resources on Immigration Reform V. Resources for Presentations/Classe