Maxillofacial and Facial Aesthetic Surgery, LTD
Physicians Name and Phone #: Shortness of Breath Sugar or Protein in Urine Deafness/Impaired Hearing Chest or Heart Pain/ Angina Skin/Autoimmune Problems Radiation Therapy High or Low Blood Pressure Arthritis/Joint Problems Epilepsy or Seizure Heart Valve Problems/Rheumatic Fever Chronic Diarrhea/Bowel Disease Emotional/Psychiatric Prob. Heart Arrythmias/Pacemaker Hepatitis B/C Frequent Headaches/Migraines Anemia/Blood Disease/Transfusion Jaundice/Liver Trouble Eye problems Heart Disease/Heart Attack/Stents Stomach/Duodenal Ulcers Glaucoma Ankle Swelling/Perfusion Issues/DVT Vomiting Blood/Black Stools Contact Lenses Frequent Colds/Cough Recent Gain or Loss of Weight Eye Dryness Asthma/Reactive Airway Disease Kidney Trouble or Nephritis AIDS/HIV Chronic Bronchitis/Emphysema Painful/Bloody Urination Limited Activity (Why?) Excessive Bleeding/Easy Bruising Neck/Lower Back Trouble Artificial Joints (Where?) Tuberculosis (Active or Treated?) Stroke/Aneurysm Are you Pregnant? Parkinson’s/Huntington’s/Alzheimer’s Facial Paralysis/Numbness/ Are You on Hormone Bell’s Palsy Replacement Therapy? Thyroid Disease (Hyper or Hypo?) Cancer/Tumor (Where?) Are taking or have you taken Bisphosphonates (Fosamax, Actonel, Bisphosphonates (Fosamax, Diabetes (Type 1 or 2) Dizziness/Fainting Boniva, Aredia or Zometa) Removable Dental Appliance Frequent and Recurrent Mouth Sores Oral Cancer/Tumor Oral Pain TMJ Dysfunction/Pain Orthodontics History Oral Surgery History Persistent Swollen Glands Sinus Problems Smoking Use: How Long and Alcohol Use: How Much and How Often? Facial Reconstructive How many Packs/Day?_____ _________________ Have you had any Have you received general Have you, or any member of your family, ever had malignant anesthetic complications? anesthetic in the past 6 hyperthermia? List Previous Hospitalizations and List All Medications including V itamins/Herbs Medications including V List All Allergies to Drugs, Anesthetic Complications Foods, Products
I certify that I have read and understand the above. I acknowledge that my questions, if any, about the inquiries set forth above have been answered to my satisfaction. I will not hold my doctor, or any member of the staff responsible for any errors or omissions that I may have made in the completion of this form. Patient Signature:_________________________________ Guardian’s Signature:______________________________ Doctor’s Initials:______
Caffeine Information Sheet In accordance with British Rowing’s Supplement Policy GB Rowing Team squad rowers should not take any supplement without the advice and supervision of your squad doctor/nutritionist. What is caffeine? • Caffeine is a naturally occurring stimulant which can be found in a wide variety of food stuffs, such as coffee, tea, soft drinks, chocolate, over
Enzympraktikum Name Schule Klasse Datum 1. Theorie - separates Dossier, im BioBuch unter Photosynthese, Zellatmung, Ernährung I. Verstehen von enzymatischen Vorgängen. II. Verhalten im Labor und Einhalten der Laborregeln. 3. Material 3.1. Kompetitive Hemmung von Amylase durch das Medikament „Glucobay“ Labormaterial Reagenzien Geräte/Apparaturen 3.2. Synthese