Patient Information and Medical History Patient Name____________________ SSN____________________________ Birth date______________________ Phone Number _______________________________ THE FOLLOWING INFORMATION IS CONFIDENTIAL. List all Medications which you If you have any allergies, currently use and why: please list them and your reaction here: (ex. Insulin for Diabetes, Motrin for Arthritis, etc.)(ex. Eggs-rash, Penicillin-short of breath, Dust-congestion, etc.)
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PAST MEDICAL HISTORY HAVE YOU EVER HAD OR BEEN TOLD THAT YOU HAD, (Please provide details for all “Yes” responses in the comment section below)
ANY PERMANENT RESTRICTIONS DUE TO A MEDICAL CONDITION
COMMENTS: Please list all surgeries or hospitalizations and date: Comments: (ex. appendectomy 1996, lumbar disc 1994, etc.) 1.____________________________________________
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Prevention Tobacco History Alcohol History
_____Used to drink but stopped in the year_____
_____Have more than one drink/day on average
_____Have more than 14 drinks/week on average
Has your cholesterol been checked in the last 5 years?
Have you had a tetanus booster within the last 10 years? Y N
Have you had the Hepatitis B vaccine series?
Y N Do you receive yearly flu shots? Y N
Comments________________________________________________________________________________________________ Family History
Has any blood relative in your family, (ie. grandparents, parents, brothers, sisters, etc.) ever had any of the following diseases, if so please indicate:
No Relationship Relationship Diabetes Tuberculosis Heart Problems Sickle Cell Disease High Blood Pressure Other____________________________________________ Females Only
Do you get regular PAP smears? Do you perform regular self breast exams Y N Please list number of times pregnant _______ When was your last menstrual period? ________ Please list the number of births To your knowledge, are you pregnant ? Y N Have you ever had a mammogram? Y N
Q(n) - A Publication of the Yale School of Management Does our health system deliver value? Competitive strategy expert Michael Porter, the Bishop William Lawrence University Professor at Harvard Business School, has shaken up the thinking around healthcare reform with Redefining Health Care , a book he coauthored with Elizabeth Teisberg, associate professor at the Darden School of Bus
Expediente : Políticas Agrícolas, ¿asuntos públicos o privados? Las economías agrícolas ya no pueden estar basadas en los modelos productivistas y exportadores que destruyen el planeta. El aumento del precio de los alimentos lo ha demostrado: hay que desarrollar los instrumentos públicos de regulación de políticas agrícolas adaptados al contexto actual, a las crisis del medio ambiente,
Patient Information and