Microsoft word - forms-_patient_registration[1].doc
PRIOR TO SEEING DR GRAZE – PLEASE COMPLETE THE FOLLOWING
((MR / MRS / MS / MISS / DR) SURNAME: ………………………………………………………………. GIVEN NAMES: .………. PREFERRED NAME……………………………………………………………………………………………. If Child: Parent/Guardian Ful Name…………………………………………………………………………. ADDRESS : ……………………………………………………………………………………………………… …… ………………………………POST CODE .DATE OF BIRTH: ……./……./……. TEL NO. (Home) ……………………. ………….(Work) ……………….……………………………………
(Mobile) ……….……………………….(Email)…………………………………………………….
NAME OF REFERRING DOCTOR: ………………………………………….…… NAME OF USUAL GP (If different to above) ……………………………………… PRIVATE HEALTH FUND …………………………………………………………. Are you covered for Private Hospital? . YES/NO…. MEMBER NUMBER ……………………………….
MEDICARE No: …………………………………. REF NO…………EXPIRY DATE ……………………. ARE YOU AN AGE PENSIONER?
YES / NO - File No…………………………….
YES / NO - Claim No………………………….
Work cover Insurer Details……………………………………………………………………………………. How did you hear about us?? GP / HOSPITAL OTHER …………………………………………………………Privacy Policy - Your consent is required for this practice to disclose information to others involved in your health care management, including treating doctors and specialists outside this practice, any medical tests or reports that are relevant to your ongoing treatment. Patient/Guardian……………………………………………………………Date…………………………….
PRIOR TO SEEING DR GRAZE – PLEASE COMPLETE THE FOLLOWING PAST MEDICAL HISTORY: It is important to list relevant current or past problems
1. Heart and Vascular System
3. Digestive System
4. Urinary System
5. DVT / Pulmonary Embolus
6. Specific ongoing joints, muscles or bone conditions 7. Brain and Nervous system
8. Previous hospitalisation or surgery 9. Are you Diabetic?
10.Are you a smoker… If so how many cigarettes per day
Medications? Is there a list of current medications on your referral?? If not please list. ………………………………………………………………………………………………………………………………
Family history of medical problems? ……………………………………………………………………………………. Allergies? (give details) …………………………………………………………………………………………………… ………………………………………………………………………………………………………………………………. OCCUPATION …………………………………… ?? RIGHT OR LEFT HANDED………………AGE.…………… Drs Notes Diagnosis/Plan
Protokoll AG-Sitzung Chirurg. Therapieverfahren, DGSM-Jahreskongress, Berlin. Protokoll der AG-Sitzung „Chirurgische Therapieverfahren in der Schlafmedizin“ der DGSM 06.12.2012, 11:30-12:45, ICC Berlin,Saal Columbus Der AG-Sprecher, Herr Professor Stuck eröffnet die Sitzung, begrüßt die Teilnehmer und dankt für deren Aktivitäten seit dem letzten DGSM-Kongress in Mannheim. Der aktuelle
Transgenic Animal Model Core Ann Arbor, MI 48109-0674 Mouse Embryonic Stem (ES) Cell Training The purpose of the class is to provide training in all aspects of ES cell culture manipulation and to provide the scientific background needed to make a gene targeted (gene knockout) mouse. You will both methods and the principles behind the methods. The Mouse Embryonic Stem Cell Training Course i