PIN STUDY - Medical Abstract - Indications (by code number) UNC variables using this list: UF14B, UF14D, UF14F, UF14H
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1 PIN STUDY - Medical Abstract - Indications (by code number) UNC variables using this list: UF14B, UF14D, UF14F, UF14H Wake variables using this list: WF14B, WF14D, WF14F, WF14H CODE INDICATION 1 LUPUS 2 GESTATIONAL DIABETES 2 DIABETES - GESTATIONAL 3 GRAVES DISEASE 4 GLUTEAL PAIN (MUSCULOSKELETAL) 5 URI 6 BACK PAIN 6 PAIN - BACK 7 SINUSITUS 8 BRONCHITIS 9 COUGH 10 ANEMIA 11 PNEUMONIA 12 INSOMNIA 13 MONILIA - YEAST INFECTION 14 PAIN 15 VAGINAL YEAST (YEAST) 16 BACTERIAL VAGINOSIS (BV) 16 BV - BACTERIAL VAGINOSIS 17 HEADACHE 18 ROUTINE 19 NAUSEA 20 RH NEGATIVE 21 UTI 22 CHLAMYDIA 23 ASTHMA 24 TRICHOMONAS 25 LABIAL HERPES 26 CONSTIPATION 27 HYPERTENSION /PROM/DATA/DOCUMENT/ABSTRACTS/IND.XLS 1
2 27 HTN - HYPERTENSION 28 POLYCYSTIC OVARY DISEASE 29 TOOTH PAIN 30 GROUP BETA STREP - GBS 30 GBS - GROUP BETA STREP 31 SYPHILIS 32 OTITIS - EAR INFECTION 32 EAR INFECTION - OTITIS 33 GONNORHEA - GC 34 GC,UTI 33 GC - GONNORHEA 35 URINARY NTRATES 36 BACTERIAL VAGINISTIS 37 RASH - ARMS 38 GROIN STRAIN 39 ABDOMINAL PAIN 39 PAIN - ABDOMINAL 40 IMPACTED TOOTH 41 MIGRAINE 42 HYPHAE 43 SINUS HEADACHE 43 HEADACHE - SINUS 44 DECREASED APPETITE, WEIGHT LOSS 45 HIV 46 DIZZINESS 47 CALCIUM 48 ECZEMA 49 INCREASED BLOOD PRESSURE 50 VOMITING 51 COUGH & CHILLS 52 ABSCESS TOOTH 53 INDIGESTION 54 GIP-DIABETES 55 CERVICITIS 56 LEG CRAMPS 57 DEPRESSION 58 DIARRHEA /PROM/DATA/DOCUMENT/ABSTRACTS/IND.XLS 2
3 59 POSTPARTUM DEPRESSION 60 PNEUMONIA RISK 61 LOW GRADE FEVER 62 PNV - PRENATAL VITAMINS 62 PRENATAL VITAMINS - PNV 63 IRON SUPPLEMENT 64 CONTRACEPTION 65 SCABIES 66 QD SUPPRESSION 67 HYPEREMEMIS 68 PHARYNGITIS 69 KNEE PAIN 69 PAIN - KNEE 70 HYPER THYROID 71 CANDIDA 72 JOINT PAIN & BRUISING 73 COUGH/FEVER 74 HSV (GENITAL HERPES) 75 REFLUX 76 COLD/HEADACHE 77 COLD 78 PHROPHYLAXIS FOR FLU 79 VOMITING & NAUSEA (N & V) 79 NAUSEA & VOMITING (N & V) 80 CONTRACTIONS 81 DIABETES 82 STREP THROAT 83 INCREASED HEART RATE 84 HYPERTROPIC SHUNTS 85 LOW HCT 86 RASH 87 PAIN / CASTROCHRONRITIS 88 WBCS CLUE 89 DOESN'T DRINK MILK / DAIRY PRODUCTS 90 FALSE LABOR 91 EMESIS 92 GIP /PROM/DATA/DOCUMENT/ABSTRACTS/IND.XLS 3
4 93 RINGWORM 94 HEARTBURN 95 VAGINAL ITCHING 95 ITCHING - VAGINAL 96 PRE-OP 97 NOT A VALID INDICATION CODE 98 LICE 99 NOT A VALID INDICATION CODE 100 PRE-ECLAMPSIA PREVENTION 101 TSH ETA 102 CONGESTION 103 NASAL CONGESTION 104 DEGENERATING FIBROIDS 105 PTL (PRETERM LABOR) 105 PRETERM LABOR (PTL) 106 VAGINAL DISCHARGE, PRESUMED INFECTION 106 DISCHARGE - VAGINAL 107 YELLOW, WHITE DISCHARGE 108 HJV 109 CRAMPING 110 PTYALISM 111 HIP PAIN 111 PAIN - HIP 112 GASTROPARESIS 113 DYSERIA 114 RASH - BACK 115 PAIN - ANKLE 116 BIPOLAR 117 PIH 118 SKIN LESION 119 DM 120 HEMORRHOIDS 121 PAIN - BREAST 121 BREAST PAIN 122 ITCHING 123 SINUS 124 CHOLESTASIS /PROM/DATA/DOCUMENT/ABSTRACTS/IND.XLS 4
5 125 FLU 126 PLACENTA PREVIA 127 FOLLICULITIS 128 IMPETIGO 129 FREQUENT URINE 130 HIVES 131 AYSURIA 132 RASH - VULVAR 132 VULVAR RASH 133 INCREASED BILE ACIDS 134 CRT SMOKING 136 IDDM 137 SUPRESSION OF B 138 ALLERGY 139 ARM PAIN 139 PAIN - ARM 140 BP CONTROL - BLOOD PRESSURE 140 BLOOD PRESSURE CONTROL 141 HCT 142 PROPHYLACTIC 143 E COLI 144 ACNE 145 PAIN - CHEST 145 CHEST PAIN 146 DYSPEPSIA 147 SEIZURES 148 BURNING WITH URINATION 149 UTERINE FIBROIDS 150 POLYMYOSITIS 151 HYPOGLYCEMIA 152 ROUND LIGAMENT PAIN 152 PAIN - ROUND LIGAMENT 153 TINEA CORPORIS 154 PAIN - SHOULDER 154 SHOULDER PAIN 155 VAGINAL WARTS - CONDYLOMA /PROM/DATA/DOCUMENT/ABSTRACTS/IND.XLS 5
6 155 CONDYLOMA - VAGINAL WARTS 156 TICK BITE 157 BACTERIURIA 158 CONJUNCTIVITIS 159 TONSILLITIS 160 POSITIVE NITRATES 161 PANIC ATTACK 162 RH STATUS 163 VIRAL GASTROENTERITIS 164 PYELONEPHRITIS 165 SORE THROAT 166 SIGNIFICANT BACTERIA 167 CRACK CRAVINGS & DEPRESSION 168 OTITIS MEDIA W/ BRONCHITIS PINCHED NERVE 171 RH INCOMPATIBILITY 172 EYE INFECTION 173 RESPIRATORY TRACT INFECTION 174 UNSPECIFIED INFECTION 175 TINEA VETSICOLOR 176 INSOMNIA & ROUTINE 177 BACTERIAL VAGINOSIS & TRICHOMONAS 178 MYCOSIS ON HER NECK 179 LUNG INFECTION 180 PRN (AS NEEDED) 181 SINUSITIS & BRONCHITIS 182 PRURITIS BETWEEN BREASTS 183 VACCINATION 184 STREP PHARYNGITIS 185 HERPES GESTATIONALIS 186 SLEEP 187 WHEEZING 188 KOH POSITIVE 189 DEEP VENOUS THROMBOSIS 190 POSITIVE CLUE CELLS 191 FLU-LIKE SYMPTOMS & ASTHMA 192 DEHYDRATION 193 PROPHYLAXIS 194 FLU & SINUSITIS 195 CONGESTIVE HEART FAILURE 196 RECTAL BLEEDING 197 CTXNS 198 ROUND LIGAMENT VERSUS KIDNEY PAIN 199 VAGINAL ITCHING & YEAST INFECTION 200 CUTANEOUS CANDIDIASIS 201 KIDNEY DISEASE 202 GONOCOCCUS INFECTION 203 HEARTBURN & NAUSEA 204 ^ B P /PROM/DATA/DOCUMENT/ABSTRACTS/IND.XLS 6
7 205 RASH-ITCHING 206 Hx EMBOLISM 207 EMBOLISM PROPHYLAXIS 208 SHORTNESS OF BREATH 209 HYPOTHYROIDISM 210 DENTAL PROCEDURE 211 PUPPPS 212 KIDNEY STONES 213 GDM 214 EXPOSURE TO CHLAMDIA 215 PRURITIS 216 VIRAL SYMPTOMS 217 GUM INFECTION 218 STUDY/FE STUDY 218 FE STUDY/STUDY /PROM/DATA/DOCUMENT/ABSTRACTS/IND.XLS 7
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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
New Patient Medical History Intake Form
New Patient Medical History Intake Form Name: Todays Date: / / Date of Birth: / / Age: Gender: M / F Marital Status: S M D W Address: City: State: Zip Code Primary Ph.# (cell, hm, wk) Email Address 2nd
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
MEDICAL INFORMATION. SECTION 1: Pharmacy Information. Pharmacy Name and Address: Pharmacy Phone Number: SECTION 2: Social History
MEDICAL INFORMATION TODAY S DATE: SOCIAL SECURITY NUMBER: PATIENT NAME: BIRTHDAY: HEIGHT: WEIGHT: AGE: WHO REFERRED YOU? RACE: PRIMARY CARE PHYSICIAN: SEX: DOCTOR S ADDRESS: SECTION 1: Pharmacy Information
Patient Medical History
#3 1810, 8 th Street East, Saskatoon SK S7H0T6 Phone (306) 373-5209 Fax (306) 373 5207 Michelle Kormos, Osteopathy (current study) Patient Medical History Please complete the entire medical history and
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Patient General Information
Patient General Information Name: (first) (middle) (last) Date of Birth: / / (mo) (day) (year) 中 文名字 : Gender: Occupation: Address: (street, apt) Phone #: (city, state, zip code) Email: Emergency Contact:
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
Emotional Relationships Social Life Sexually Recreation
Name Date Address City State Zip Married Single Partner Divorced Widowed Date of Birth SS# Email Work Phone Home Phone Cell Phone Occupation Referred by Emergency Contact Family Physician Contact May we
Bend Surgical Associates. Michael J. Mastrangelo, MD, FACS. Medication Name Dosage Frequency Medication Name Dosage Frequency
Bend Surgical Associates Michael J. Mastrangelo, MD, FACS PATIENT NAME: DATE F BIRTH: MEDICATINS Please list all of your current prescription, non-prescription medications, vitamins, minerals, and supplements.
New Patient Medical History Form
New Patient Medical History Form Date: Name: Date of Birth: Address: City: ZIP: Home Phone #: Cell Phone #: Emergency Contact: Relationship: Emergency Contact Phone #: Primary Care Physician: Referring
I understand cancellation policy. OCCUPATIONAL INFORMATION PHYSCIAN INFORMATION INSURANCE INFORMATION
PERSONAL INFORMATION NAME: TODAY'S DATE: ADDRESS HEIGHT: WEIGHT: DATE OF BIRTH: AGE: GENDER: PHONE: HOME MOBILE WORK EMAIL ADDRESS: EMERGENCY CONTACT: STATUS: SINGLE MARRIED DIVORCED WIDOWED OTHER: NUMBER
Name Age Date. Please list All your current health complaints, including the reason that brought you to our office:
Name Age Date Please list All your current health complaints, including the reason that brought you to our office: List any other doctors see for current problems and list treatment received and results:
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
LTASEX.INFO STI SUMMARY SHEETS FOR EDUCATIONAL USE ONLY. COMMERCIAL USE RIGHTS RESERVED. COPYRIGHT 2013, JEROME STUART NICHOLS
LTASEX.INFO STI SUMMARY SHEETS FOR EDUCATIONAL USE ONLY. COMMERCIAL USE RIGHTS RESERVED. COPYRIGHT 2013, JEROME STUART NICHOLS LTASEX.INFO! IN AIDS is a treatable complication of advanced HIV infection.
PULMONARY CARE OF CENTRAL FLORIDA, P.A. Date: / /
PULMONARY CARE OF CENTRAL FLORIDA, P.A. Date: / / Patient Name Age DOB: / / Family Physician Referring Physician Telephone Number Telephone Number Pharmacy: Phone: Fax: MEDICAL HISTORY 1. What is your