Honduras New Hope Clinic Weekly Reports. November Weekly Report Nov. 3-7, 2014
|
|
|
- Vivian Hall
- 5 years ago
- Views:
Transcription
1 Honduras New Hope Clinic Weekly Reports. November 2014 Weekly Report Nov. 3-7, 2014 This week we saw a total of 100 patients, 34 of whom were unable to pay because of limited financial This week I took care of a 62 year old man who came in as an emergency in very bad condition because of dehydration suffered from diarrhea accompanied in the last two evacuations. The patient had had diarrhea for more than 48 hours and the family members worsened the situation by giving him a dose of folk medicine that caused even more diarrhea because the effect of this was as a laxative. Thanks to the Lord after giving him liquids and antibiotics intravenously, after 6 hours of hydration and antibiotics the vital signs of the patient improved. We are treating him now as an ambulatory patient. Thanks to the Lord the patient improved satisfactorily. This week we carried out a campaign to eliminate trash to eliminate possible creatures that cause dengue with the elementary and high school students of Guayape. The community leaders and water board leaders also helped us. 1 patient with dysentery 2 patients for treatment of elevated uric acid 1 patient with carpal tunnel neuralgia 2 patients with muscle spasms 3 patients with possible anemia 2 patients with Pterygium 3 patients with urinary infections 2 patients with depression syndrome 1 patient with grade I sprain 1 patient with exophthalmos 2 patients with bronchitis 2 patients for wound cleaning 3 patients with throat infections 2 patients with classic dengue 2 patients with irritable colon problems 2 patients with migraine type headache 5 patients with gastroenteritis 2 patients with grade II varicose veins 2 patients with gingivitis 3 patients for Pap smears 2 patients with acute malnutrition 2 patients for family planning 2 cases of bronchial asthma 2 patients with athlete's foot 2 patients with torticollis 3 prenatal visits 3 patients with high cholesterol and triglycerides 12 patients for hypertension control 12 patients for diabetes control 2 patients for circulation problems in the legs
2 2 patients with infected wounds 2 patients with hemorrhoid problems 10 common colds This week we saw a total of 44 patients, 7 of whom were unable to pay because of limited financial Extractions 33 Cleanings 2 Fillings 22 Dental Surgery 0 Weekly Report Nev , 2014 This week we saw a total of 91 patients, 37 of whom were unable to pay because of limited financial This week I attended an emergency birth. The patient is 38 years old with a history of four previous pregnancies. When the patient arrived she was fully dilated. At birth we realized that the child had a double cord circle (this means that the child had the umbilical cord wrapped around the neck and if this problem were not corrected would have been asphyxiated). After the birth the child was a little lethargic. We administered oxygen and reanimated him. After a couple of minutes the child began to cry energetically and became active. We were all very happy that the moment of tension we had experienced was over upon seeing the baby was not crying. This Dr. Gonzales gave a talk on oral hygiene in the school in Rio Arriba where we also did a clean-up campaign in the community to eliminate mosquitos. 1 patient for birth 2 patients for family planning 2 patients for repositioning of IUD 2 patients with shingles 2 patients for checkups after treatment for Helicobacter Pylori 2 patients for wasp stings 1 patient with nasal polyp 1 patient with a foreign object in the right ear (a match head) 2 patients with halitosis caused by poor oral hygiene 1 patient with a foreign object in the right eye 5 common colds 1 patient with chicken pox 2 patients with bronchitis 1 patient with possible myopia
3 2 patients with allergic dermatitis 2 patients with infected wounds 2 cases of bronchial asthma control 1 patient for suture removal 1 patient with epistaxis 4 patients recalled for Pap smear results and treatment 2 patients for catheter change 2 patients for hair loss 2 patients with sinusitis 1 patient with vaginal infection from candidiasis 2 cases of control for gastritis 2 patients with slight anemia as shown by lab results 2 patients with hemorrhoids 2 patients with dental abscess 1 patient with throat infection 2 patients with inner ear infections 1 patient with diarrhea syndrome and moderate dehydration 3 prenatal visits 3 Pap smears 2 patients with vaginal tricomoniasis 8 patients for hypertension control 7 patients for diabetes control 1 patient with light pneumonia 2 patients with allergic dermatitis 2 patients with cataract in the left eye 2 patients with Torticollis 2 patients with vaginal gardnerella 1 patient with menstrual delay because of pregnancy This week we saw a total of 22 patients, 6 of whom were unable to pay because of limited financial Extractions 10 Cleanings 0 Fillings 20 Dental Surgery 1 Weekly Report Nov , 2014 This week we saw a total of 103 patients, 38 of whom were unable to pay because of limited financial
4 This week I sent a newborn to Tegucigalpa with signs of fever and with signs of umbilical infection. The birth of the baby was attended by a midwife who when cutting the umbilical cord used a knife that had been inadequately sterilized. At ten days after birth the baby's temperature was 38.8 degrees C. and was red around the umbilical area. The child was admitted to emergency and treated adequately. Antibiotics were administered and also a tetanus shot. This week a fair was organized in the village of San Francisco in honor of St. Francis of Assisi. We participated in the health area and were part of the judging to select the best native costume of the fair. 1 patient with umbilical cord infection 1 patient with multiple trauma 1 patient with possible ovarian cyst 1 patient with probable kidney stones 1 patient with foreign object in the right eye 1 patient with dental abscess 2 patients for hemorrhoid control 5 patients recalled for Pap smear results and treatment 3 patients with throat infections of probable viral type 2 patients with gardnerella 2 patients with rhinitis 1 patient with bacterial conjunctivitis 2 patients for asthma control 3 patients with sinusitis 1 patient with seborrhea dermatitis 3 patients with bronchial asthma 1 patient with menstrual pains 2 patients with contact dermatitis 2 patients with ear irrigation for wax 1 patient with suppurative inner ear 2 patients for catheter change 3 patients with bacterial type tonsillitis 2 patients with senile cataracts 4 cases of gastritis 2 patients for wound cleaning 4 patients with irritable colon problems 2 patients for lumbago 1 patient with sciatic nerve neuralgia 3 patients with gastroenteritis 2 patients with back muscle pain 2 patients for grade I sprain 3 patients with acute diarrhea syndrome 2 patients for athlete's foot 2 patients with insomnia problems 1 patient for IUD repositioning 1 patient for anxiety syndrome 1 patient with menstrual delay because of pregnancy 11 patients for hypertension control
5 10 patients for diabetes control 3 patients for family planning 2 patients with high cholesterol 2 patients with intestinal parasites This week we saw a total of 28 patients, 8 of whom were unable to pay because of limited financial Extractions 7 Cleanings 2 Fillings 29 Dental Surgery 1
Clinica Nueva Esperanza May 2014 Reports. Weekly Report May 5-9, 2014
Clinica Nueva Esperanza May 2014 Reports Weekly Report May 5-9, 2014 This week we saw a total of 85 patients, 35 of whom were unable to pay because of limited This week I took care of a 6 year old boy
Honduras New Hope Clinic Weekly Reports, August Weekly Report August 3-7, 2015
Honduras New Hope Clinic Weekly Reports, August 2015 Weekly Report August 3-7, 2015 This week we saw a total of 82 patients, 35 of whom were unable to pay because of limited financial This a 32 year old
New Hope Clinic Weekly Reports March Weekly Report March 2-6, 2015
New Hope Clinic Weekly Reports March 2015 Weekly Report March 2-6, 2015 This week we saw a total of 100 patients, 30 of whom were unable to pay because of limited financial I sent a 4 year old girl to
This week we saw a total of 85 patients, 25 of whom were unable to pay because of limited financial resources.
February 2014 Honduras New Hope Clinic Weekly Reports Weekly Report Feb. 3-7, 2014 This week we saw a total of 85 patients, 25 of whom were unable to pay because of limited This week the clinic donated
This week I gave a talk on dental hygiene and organized a clean-up operation with the students in Los Perez.
Honduras New Hope Clinic February 2016 Weekly Reports Weekly Report Feb. 1-5, 2016 This week we saw a total of 90 patients, 29 of whom were unable to pay because of limited financial This week we saw an
Medical History Form
Medical History Form NAME DOB / / TODAY S DATE MEDICAL HISTORY What medical Conditions do you have? Select all that apply, or write in if not listed: Diabetes High Blood Pressure Thyroid Disorder Heart
PATIENT INFORMATION FORM (WOMEN ONLY)
PATIENT INFORMATION FORM (WOMEN ONLY) Name: Age: Sex: Birthdate: / / SS # A. Describe briefly your present symptom(s) or the reason(s) for seeing the doctor today: B. Name all illnesses or conditions for
Welcome to About Women by Women
Welcome to About Women by Women Today s Date New Patient Questionnaire Name: Birth Date: / / Home Phone: Address: Cell Phone: Work Phone: Occupation: Employer: Marital Status: Married Living w/ Partner
what vitamins are what vitamins are for
what vitamins are and what vitamins are for www.eurovit.eu page 1/23 Vitamins are essential for human body life. Vitamins are organic compounds that are needed in small quantities to sustain life. No vitamins
EVIDENCE-BASED VITAMIN AND MINERAL USAGE SUMMARY TABLE (APRIL 2002)
Acne Acrodermatitis Enteropathica Adrenal Support Age Related Cognitive Decline Alcoholism/Alcohol Withdrawal Alzheimer's Disease Amenorrhoea Anaemia Angina Anorexia Nervosa Anxiety Asthma Atherosclerosis
Premium Specialty: Pediatrics
Premium Specialty: Pediatrics Credentialed Specialties include: Adolescent Medicine, Pediatric Adolescent, and Pediatrics This document is designed to be used in conjunction with the UnitedHealth Premium
BACK TO BASICS HEALTH & NUTRITION COMPREHENSIVE HEALTH HISTORY
BACK TO BASICS HEALTH & NUTRITION COMPREHENSIVE HEALTH HISTORY Thank you for choosing Back To Basics Health & Nutrition to assist you with your natural health care. The ability to draw effective conclusions
ALASKA COMMUNITY HEALTH AIDE PROGRAM Standing Orders-January CHA/P Name: Village:
CHA/P Name: Village: Tribal Health Organization: is authorized to treat patients with the Alaska Community Health Aide/Practitioner Manual (echam) ASSESSMENTS that are initialed below according to the
Wynne Huang, M.D. Family Medicine
PATIENT INFORMATION Last Name: First Name: Middle Initial: Date of Birth: SS#: - - Address: City, State, Zip Code Single( ) Married( ) Partner( ) Divorced( ) Widowed( ) Legally Separated( ) Male( ) Female(
Name Age DOB Sex M F Your relationship status: Single Married Life partner Widowed Address
Today s Date Contact Information Name Age DOB Sex M F Your relationship status: Single Married Life partner Widowed Address Phone numbers and E-mail (please check numbers to call or leave a message) Home
LAKES INTERNAL MEDICINE
LAKES INTERNAL MEDICINE HEALTH HISTORY QUESTIONNAIRE Please print this and complete and bring to your initial appointment. Today's Date Last Name First Name Middle Initial Date of Birth Male Female Education
Patient History Form
Patient History Form Advanced Directive Care Plan? Yes No Name: Birth date: / / Address: Age: Sex: F M STREET DAY YEAR Telephone: Home ( ) CITY STATE DAY YEAR MARITAL STATUS: Divorced Separated Alive/Age
Pure Health Natural Medicine
Pure Health Natural Medicine Female Intake Date: Personal Information Name: (first, last) Maiden: Preferred Name: Sex: M F Date of Birth: Age: Street Address: City: State: Zip: E-mail Home Phone: Cell
Adult Health History
Patient Name Date of Birth Adult Health History This form will assist us in obtaining a complete medical history and health record on you. By completing this ahead of time it will also simply your visit
Adult Health History for NEW Patients
Adult Health History for NEW Patients Your answers on this form will help your health care provider get an accurate history of your medical concerns and conditions. If you are a current patient there is
On a scale of 1 10 ("10" being optimal health) please rate where you feel your health is in the the areas below:
Healthcare History djp Pure-Health wellness centre www.pure-health.com Wellness Profile General Health On a scale of 1 10 ("10" being optimal health) please rate where you feel your health is in the the
Rockwood Natural Medicine Clinic
Rockwood Natural Medicine Clinic 9755 N. 90 th St., Suite A-210 Scottsdale, Arizona 85258 480-767-7119 Date: Name: Age: Sex: M F Are you: Married Separated Divorced Widowed Single How did you hear about
DEPARTMENT OF MEDICINE Outpatient Intake Form
NAME: Last First Middle Initial Date of Birth: ADDRESS: HOME PHONE: WORK PHONE: Did someone refer you here? Yes No If yes, please give name: Main reason for your visit today: MEDICAL HISTORY: (Please check
Medical History Form
General: Medical History Form 1. Chief Complaint: What are the main health concerns you wish to address? 2. Current and Past Treatment: Have you received treatment for these problems? Yes No, if yes, which:
Inflammatory Bowel Disease Medical Exam Questionnaire
Patient Name: MR: Date: Name DOB / / Age Marital Status Race Gender M / F Height Present Weight Usual Weight Insurance Managed Care Self referral Yes No Yes No Yes No Primary Care Physician Referring Physician
Adult Health History Summary
Adult Health History Summary Name Age Date of Birth Address City Province Postal Code Phone (home) (cell) Occupation Email May we contact you via email? YES NO Emergency Contact Phone # How did you hear
BROADWAY SPORTS & INTERNAL MEDICINE, P.S TH AVE NE SUITE 202 BELLEVUE, WA P: F:
BROADWAY SPORTS & INTERNAL MEDICINE, P.S. 1600 116 TH AVE NE SUITE 202 BELLEVUE, WA 98004 P: 206 215-2288 F:206 215-2289 MEDICAL HISTORY QUESTIONNAIRE Date Name Date of Birth HT WT Current Medical Complaints
Who is filling out this intake form? Self Spouse Parent Guardian
Office Use Only: Reviewed with Patient Data Entry Scan & File Date: Date: Date: Initials: Initials: Initials: Today s Date: Who is filling out this intake form? Self Spouse Parent Guardian If you are not
DOB: / / Please list the names and telephone numbers of the other physicians involved in your care: Name Specialty Phone Address Receive Report (Y/N)
Medical History: Patient: DOB: / / Please list the names and telephone numbers of the other physicians involved in your care: Name Specialty Phone Address Receive Report (Y/N) List the names of prescription
DEPARTMENT OF MEDICINE Outpatient Intake Form
NAME: Last First Middle Initial Date of Birth: ADDRESS: HOME PHONE: WORK PHONE: Did someone refer you here? Yes No If yes, please give name: Main reason for your visit today: MEDICAL HISTORY: (Please check
Bridges Family Wellness PC. New Patient Intake. Bridges Family Wellness Intake Form SE Lake Rd, Suite 102 Milwaukie, OR
New Patient Intake Bridges Family Wellness Intake Form Full Name: * What is your birthdate? MM/DD/YYYY * What is your gender identity? * Home address: * Cell Phone * Other Phone number(s): Emergency Contact
WELCOME to Naturopathic Medicine at Vivo!
1 WELCOME to Naturopathic Medicine at Vivo! What You Can Expect: 1 st Appointment: Your first appointment is up to 1 hour and 30 minutes; this includes a detailed patient intake, a complete health history,
Supplementary appendix
Supplementary appendix This appendix formed part of the original submission and has been peer reviewed. We post it as supplied by the authors. Supplement to: Williams CM, Maher CG, Latimer J, et al. Efficacy
ETG Analyzer Report. Your Practice # Episodes. Mkt Share Mkt Volume WHIO Dermatology 575 Acne 746 $508 1,698 $
ETG Analyzer Report Practice: Practice Group: Badger County Severity: Level 1 Payers: Commercial Episode Types: Complete Claims: Full Claims Outliers: No Outliers DMV6 Created: April 1, 2010 March 31,
Patient Information. Marital Status (Single, Married, Life Partner, Divorced, Widowed) CHIEF COMPLAINT
Patient Information Name Date Home Address City State Zip Phone E-mail Address Cell Phone: Business Address City State Zip Phone Occupation Place of Birth Date of Birth Age Height Weight Soc. Sec. # Sex
Diana Quinn, ND Integrative Healthcare Providers 3053 Miller Rd Ann Arbor, MI P (734) F (734) New Patient Intake Form
Diana Quinn, ND Integrative Healthcare Providers 3053 Miller Rd Ann Arbor, MI 48103 P (734) 547-3990 F (734) 547-3890 New Patient Intake Form Personal Information Name Age Sex Female Male Gender Identify
Functional Blood Chemistry & CBC Analysis
Functional Blood Chemistry & CBC Analysis Session 11 Immune Markers Immune Dysfunctions Immune Deficiency, Allergies, Immune Over Activity Causes of Immune Dysregulation External Influences Pharmaceutical
Date First Name Middle Name Last Name. SSN Sex Birth Date Height Weight. Marital Status Spouse Name Number of Children. Address City State Zip
PATIENT INFORMATION Date First Name Middle Name Last Name SSN Sex Birth Date Height Weight Marital Status Spouse Name Number of Children Address City State Zip Home Phone Cell Phone Email Emergency Relation
Sound View Acupuncture and Chinese Herbs 5410 California Ave SW, #202, Seattle, WA
Sound View Acupuncture and Chinese Herbs 5410 California Ave SW, #202, Seattle, WA 98136 206.200.3595 Today s date Name Legal name (if different) Phone (primary) (secondary) Address City State Zip Email
THE NEPAL TRUST Working with Health, Community Development & Hope in the Hidden Himalayas Primary Healthcare Programme
THE NEPAL TRUST Working with Health, Community Development & Hope in the Hidden Himalayas Primary Healthcare Programme Detail Abstract OPD Services 2014 Detail Abstract The Nepal Trust OPD Services in
WELCOME TO UBMD FAMILY MEDICINE OF AMHERST. Thank you for selecting your Primary Care Physician with UBMD Family Medicine of Amherst.
WELCOME TO UBMD FAMILY MEDICINE OF AMHERST Thank you for selecting your Primary Care Physician with UBMD Family Medicine of Amherst. Some things to do before your visit Please call your health insurance
Headache Follow-up Visit Form
!1 Headache Follow-up Visit Form We will be unable to see you unless this form is completely filled out. We appreciate your thoroughness. Name DOB Age Today s Date Referring doctor: Primary doctor: Neurologist:
How It Spreads Symptoms Can Include Complications
OUR BEST SHOT: The Importance of Vaccines for Older Adults VACCINES QUICK GUIDE TO VACCINATION FOR ADULTS AGES 60+ Vaccines are an important step in protecting your health and the health of your family.
Family Naturopathic Clinic
Mark Orbay, B.Sc., N.D. Doctor of Naturopathic Medicine 265 Carling Avenue, Suite 610 Tel: (613) 230-6100 Fax: (613) 230-0070 Name: Phone (Home) Address: (Office) Date of Birth: / / Age: (Month) (Day)
ACUPUNCTURE INTAKE FORM
, ND ACUPUNCTURE INTAKE FORM Thank you for taking the time to complete the following new patient forms. Given this form is extensive, it plays an integral role in achieving our mutual goal of your optimal
Alivia Acupuncture Clinic, LLC. Address. City State Zip. . Occupation Employer. Emergency contact Relationship. Primary Care provider Phone
Alivia Acupuncture Clinic, LLC Karla Sourasky Olmos, L. Ac Patient Information Name Age Date of birth Address City State Zip Email Home Phone Work phone Cell Phone Marital Status Single Married Divorced
Personal Health Risk Appraisal
Today s Date: Premier Arthritis and Osteoporosis Center 722 North Fairfield Road Beavercreek, OH 45434 Phone (937) 208-7000 Fax (937) 208-7010 Personal Health Risk Appraisal Last Name: First Name: MI:
Oriental Medicine Questionnaire
Oriental Medicine Questionnaire Date: Name: DOB Sex: M F SS# Address: City State Zip Cell Phone: Home Phone: Business Phone Occupation: Height: Weight: Who referred you to this office? 1.What brought you
APR-DRG Description Ave Charge
Abdominal Pain 16,500.25 2.8 6,000.09 Acute & Subacute Endocarditis 15,339.30 3.0 5,113.10 Acute Myocardial Infarction 17,687.46 2.6 6,802.87 Alcohol Abuse & Dependence 19,126.64 4.2 4,553.96 Alcoholic
TABLE OF CONTENTS INTRODUCTION DIGESTION SUGAR HANDLING MUSCULOSKELETAL. Introduction I
INTRODUCTION TABLE OF CONTENTS Introduction I DIGESTION Acid Indigestion D1 Excessive Appetite D9 Reduced Appetite D13 Biliary Insufficiency D19 Colitis D27 Constipation D33 Dry Mouth D39 Dysbiosis D43
Caspian Acupuncture -- Health History Form Anita Tayyebi EAMP, LAc. 652 SW 150 th St Burien WA 98166
Frist Name Last: Date Phone (H) (C) (W) E-mail Address City State Zip Age DOB Place of Birth _ Marital/Partnership Status Preferred Gender Pronoun _ Profession Family Physician Telephone # Referred By
Date First Name Middle Name Last Name. SSN Sex Birth Date Height Weight. Marital Status Spouse Name Number of Children. Address City State Zip
PATIENT INFORMATION Date First Name Middle Name Last Name SSN Sex Birth Date Height Weight Marital Status Spouse Name Number of Children Address City State Zip Home Phone Cell Phone Email Emergency Relation
Application For Admission Jersey Shore Low Back Center DRX 9000 Severe Back Pain Solution Program
Application For Admission Jersey Shore Low Back Center DRX 9000 Severe Back Pain Solution Program If you are reading this you have been fortunate enough to qualify for a consultation with Dr. Zammito at
Lecture 2 Chemical and Biological Agents
Lecture 2 Chemical and Biological Agents In the Chemical ad Biological section, Routes of exposure we will be covering: Forms of Chemical agents Examples of chemical agents Forms of Biological agents Classifications
New Patient Intake Form Pickering Chiropractic Health Centre 1154 Kingston Road Pickering ON, L1V 1B4
New Patient Intake Form Pickering Chiropractic Health Centre 1154 Kingston Road Pickering ON, L1V 1B4 Date: Name Age Date of Birth Address Postal Code Occupation Phone (home) (work) Okay to leave a message?
CHRISTOPHER BROWN D.O. - TRADITIONAL OSTEOPATHY
CHRISTOPHER BROWN D.O. - TRADITIONAL OSTEOPATHY REGISTRATION PAGE Date: Name: Tel: 510-526-5256 (Albany) 415-334-1010 (San Francisco) Fax: 510-526-5547 christopherbrowndo@gmail.com DOB: Age: Sex: Address:
UnitedHealth Premium Physician Designation Program Episode Treatment Groups (ETG ) Description and Specialty
UnitedHealth Premium Physician Designation Program Episode Treatment Groups (ETG ) Description and Specialty 666700 Acne Family Medicine, Internal Medicine, Pediatrics 438300 Acute Bronchitis Allergy,
Recommended Preventive Care Snapshot
Preventive Care Recommendations For quick reference, this snapshot provides a general list of preventive care recommendations that you and your family members may need to consider. It also describes what
Creve Coeur Family Medicine, LLC
Creve Coeur Family Medicine, LLC Patient Name: Date of Birth: Medication List Medication Name (Over the counter medications too) Strength/ Dose (mg) Number of pills per dose Number of times per day Personal
Patient s Name: Birthdate: (dd/mm/yyyy) Sex: Mailing Address: Phone Number: Family Doctor or Paediatrician. How did you hear about the clinic?
Pediatric Intake Form Thank you for taking the time to fill out this form. This information is very important in order to best assess your child s needs. Patient s Name: Birthdate: (dd/mm/yyyy) Mother`s
SCHNEIDER MEDICAL GROUP, PA History Intake Form (Please Print)
History Intake Form Patient Name: Date of Visit: Briefly State the reason for the visit: Date of Birth: Physician Use Only - History and Present: 1. 2. 3. 4. 5. Page 1 of 10 Review of Symptoms HEAD NO
0301 Anemia Others. Endocrine nutritional and metabolic disorders Others Vascular dementia and unspecified dementia
Certain infectious and parasitic diseases 0101 Intestinal infectious diseases 0102 Tuberculosis 0103 Infections with a predominantly sexual mode of transmission 0104 Viral infections characterized by skin
PLEASE NOTE: WE ARE A FRAGRANCE FREE BUILDING. *(Please circle answer where ever there is a multiple question.)
1 Dr. Stephen Maltais ND, Naturopathic Doctor 88 Dover Mills Road, Port Dover, ON. N0A 1N1 Phone: (519) 583-1234 E-mail: docmaltais@kwic.com www.dovernaturoapth.com INTAKE FORM FEMALE (16 years of age
Health Intake Form. Name: Prefer Name: Date: City: State: Zip Code: Gender: M F. Telephone # (home): (work): (Cell):
Health Intake Form Name: Prefer Name: Date: Address: Age: City: State: Zip Code: Gender: M F Telephone # (home): (work): (Cell): Email Address: Date of Birth: Marital Status: Married Separated Divorced
ICD and SERVICE CODES FOR FREE TEXT FACILITY
ICD and SERVICE CODES FOR FREE TEXT FACILITY ICD 9 ICD 10 Diagnoses SMS Svc Code Procedures (OP) 285.9 D64.9 ANEMIA NOS PA01 Complete Blood Count (Hemoglobin) 493.9 J45.9 ASTHMA NOS* PA04 Skin Test 493.9
DENAS PCM Operating Manual. Part II. Usage Instruction. 4th generation of device. English. Russian. French. German
TRONITEK LLC, Yekaterinburg, Russia 4th generation of device DENAS PCM 2014 English Operating Manual Russian Part II. Usage Instruction French German ТРТК 04.3-03.70 РЭ ТУ 9444-009-44148620-2009 The company
stoneburner acupuncture
STONEBURNER ACUPUNCTURE, LLC Erin K. Stoneburner, LAc, MAcOM 1135 SE Salmon St, Suite 211 503.784.1660 stoneburner@gmail.com Date: Name: (First) (Middle) (Last) DOB: _ Age: Sex: Address: City/State: ZIP:
The TMJ Therapy Effects of Joint Manipulation
The overall postural structure associated with TMJ disorders is part of the The TMJ Therapy concern. Chiropractic manipulation has helped realign the joints in your TMJ, neck, and low back and along with
Patient History Form
Patient Personal Information Name: Date: Age: Occupation: Employer's name: Briefly describe your daily activities at work: Sex: male female Marital Status: single married divorced widowed Spouse's name:
MEDICAL HISTORY (To be filled in by patient)
MEDICAL HISTORY Reason for Visit or Chief Complaint: Referred By: Present Illness: (To be filled in by Physician) I. Have you had any reactions, allergies or bad effects from any of the following: Serum
NOTICE TO OUR PATIENTS
SMG Chestnut Street, SMG Elm Street, SMG Mancos Valley, Southwest Walk-In Care, Southwest School-Based Health Center, SMG Market Street, SMG Orthopedics, SMG Pulmonary and Sleep Medicine, SMG General Surgery,
Name: Date: Referring Provider: What is the nature of your current gynecologic or urologic medical problem (use the other side if necessary).
Name: Date: Referring Provider: Age: D.O.B. Race/ ethnicity: What is the nature of your current gynecologic or urologic medical problem (use the other side if necessary). We are interested in learning
Bahl & Bahl Medical Associates PATIENT MEDICAL HISTORY
Bahl & Bahl Medical Associates PATIENT MEDICAL HISTORY NAME: _ DATE: Please complete the following questionnaire as completely as possible. 1. MEDICAL HISTORY Please list all current and prior health problems,
DENAS T Operating Manual. Part II. Usage Instruction. 3rd generation of device. English. Russian. French. German
TRONITEK LLC, Yekaterinburg, Russia 3rd generation of device DENAS T 2014 English Operating Manual Russian Part II. Usage Instruction French German ТРТК 09.5-03.70 РЭ1 ТУ 9444-009-44148620-2009 The company
Aromatherapy
Holistic Health Practitioner and Aroma Therapist. 650-321-5600 naturaltraditions@gmail.com, jaya@naturaltraditionshealth.com Natural Traditions, 115 El Camino real, Menlo Park, CA 94025 www.naturaltraditionshealth.com
PATIENT INFORMATION Please print clearly and complete all blanks
PATIENT INFORMATION Please print clearly and complete all blanks DATE: REFERRED BY: SEX: NAME: LAST FIRST MIDDLE BIRTHDATE: MAILING ADDRESS: CITY STATE ZIP TELEPHONE: CELL PHONE: WORK NUMBER: SS # MARITAL
Avicenna Acupuncture PEDIATRIC INTAKE FORM (BIRTH TO 5 YEARS)
PEDIATRIC INTAKE FORM (BIRTH TO 5 YEARS) Date: Address: City: State: Zip: Parents Name: Telephone (cell): Parent s work #: Parent s email address: Date of Birth: Gender: How did you hear about this clinic?
Nutrition Consultation Intake Form Please write or print clearly
Artemis in the City, LLC Danielle Heard, MS, MS, HHC Clinical & Functional Nutritionist ph: 866-330-5421 fx: 212-535-3234 www.artemisinthecity.com Nutrition Consultation Intake Form Please write or print
REDROCK MEDICAL GROUP INITIAL HISTORY AND PHYSICAL
REDROCK MEDICAL GROUP INITIAL HISTORY AND PHYSICAL NAME: BIRTH DATE: AGE: SEX: M F OCCUPATION: RACE: WHO REFERRED YOU TO OUR OFFICE? _ WHAT IS YOUR MAIN COMPLAINT? HOW LONG HAS THIS BEEN A PROBLEM? IS
Ea Medical Weight Loss Services Solutions for permanent weight loss PATIENT HISTORY. When did you first become overweight? (Your age then) or Year
PATIENT HISTORY Name: Age: Date: When did you first become overweight? (Your age then) or Year How did your weight gain start? Describe any circumstances: What do you think is the cause of your weight
Integrative Consult Patient Background Form
Let Us Know More - So We Can Help Thank you for choosing to schedule an integrative medicine consultation with UC Health. To help us meet your needs during your visit, please take some time to sit in a
Vit C Cases - Shingles
Vit C Cases - Shingles Schencking M, Sandholzer H, Frese T. Intravenous administration of vitamin C in the treatment of herpetic neuralgia: two case reports. Med Sci Monit. 2010 Apr 28;16(5):CS58-61. PubMed
The Food Intolerance Institute of Australia
The Intolerance Institute of Australia The Symptoms Matrix The Symptoms Matrix allows you to narrow the possibilities of your food rather than diagnose it. To get an accurate identification of your food
Supplementary materials for:
Supplementary materials for: Cecil E, Bottle A, Sharland M, Saxena S. Impact of UK primary care policy reforms on short-stay unplanned hospital admissions for children with primary care-sensitive conditions.
NEW GYN PATIENT HISTORY FORM (OB PATIENTS, please DO NOT USE THIS FORM. Thanks.)
NEW GYN PATIENT HISTORY FORM (OB PATIENTS, please DO NOT USE THIS FORM. Thanks.) TODAY'S DATE Your age DATE OF BIRTH YOUR NAME (Last) (First) (M.I.) REFERRED HERE BY YOUR PAST MEDICAL HISTORY (If YOU have
NEW PATIENT HEALTH HISTORY
NEW PATIENT HEALTH HISTORY Debra Joan Wood, Lic Ac, MAcOM Acupuncture and Herbs Please help me provide you with a complete evaluation by taking the time to fill out this questionnaire carefully. If there
My Certification I certify that the above information is correct and I request services. X Signature of patient or person acting on patient's behalf
Owego Chiropractic, P.C. 115 Temple Street, Owego NY 13827 (607)687-3800 Patient Information Patient Name Last First Middle Initial Name you prefer to be called by (nickname) Gender (circle one) Date of
SAMPLE OF PRE-COURSE OCCUPATIONAL HEALTH QUESTIONNAIRE 2017
SAMPLE OF PRE-COURSE OCCUPATIONAL HEALTH QUESTIONNAIRE 2017 PLEASE NOTE THIS IS FOR GUIDANCE ONLY AND IS SUBJECT TO CHANGE PART A Applicant Personal Information PART B Applicant General Health Information
Inner Balance Acupuncture
Patient Information Inner Balance Acupuncture 274 Southland Drive, Suite 101, Lexington, KY 40503 859-595-2164 www.acupunctureky.com Name: Today s date: Age: Male Female Marital status: Date of Birth:
Essential Wellness Of Illinois, LLC Health History Questionnaire Christine A. Renz L.Ac., Dipl OM, MSTOM
Name Date Address City State Zip Home Phone Cell Fax Email Emergency Contact Emergency Number Date of Birth Age Sex Height Weight Lbs Marital Status Occupation Who referred you to this office? Name of
New Patient Questionnaire. Name DOB Date
Medical History (This refers to medical problems that have already been diagnosed or treated. Please explain how this is treated, such as diet, medication, surgery, etc.) Condition Abnormal Pap smear Alcohol
Sonoma Skin Dermatology - 1 Appointment Date: 3/19/2013 Name: Nickname: DOB: Age: Gender: Female Male Marital Status: S M D W O
Sonoma Skin Dermatology - Appointment Date: /9/0 Nickname: DOB: Age: Gender: Female Male Marital Status: S M D W O Spouse/Partner s SSN: DL# State: Home #: Work #: Cell Phone #: E-mail Address: Preferred
Island Acupuncture. Patient General Information. Last Name First Name. Home Phone Cell Phone. Work Phone . Date of Birth Occupation
Island Acupuncture & Massage Therapy Patient General Information GENERAL PATIENT INFORMATION Last Name First Name Home Phone Cell Phone Work Phone Email Address (street) (city) (state) (zip) Date of Birth
Employed? Yes No Employer Name. Occupation. Problem Onset Frequency Severity E.g. Headaches June times per week Mild / Moderate / Severe
PLEASE NOTE: This file must be saved to your desktop before and after completing! PATIENT INFORMATION Date First Name SSN Sex Marital Status Middle Name Birth Date Last Name Height Spouse Name Address
CLINIC. Frequently Asked Questions
About Target Clinic 1. How is Target Clinic different from a regular urgent care clinic? Target Clinic is a convenience-care clinic. Our medical professionals can diagnose and treat illnesses, minor injuries
Dr. Michelle Mackay Patel, ND
NATUROPATHIC ADULT INTAKE PERSONAL INFORMATION: First Name(s): Last Name: Date of Birth (mm/dd/yy): / / Age: What is your current gender identity? Male Female Transgender Male/Transman/FTM Transgender
New Patient Intake Form
PERSONAL INFORMATION New Patient Intake Form Name Date of First Visit Address City Province Postal Code Telephone # (home) (work) E-mail Address Relationship Status Age Date of Birth (M/D/Y) Gender: female
Cold & Flu Information
Cold & Flu Information We urge you to keep children with symptoms of cold or flu at home. Please read guidelines below to help you decide if you should keep your student home. Consider keeping children