The Socioeconomic Cost of Chronic Rhinosinusitis (SoCCoR) Study
|
|
|
- Ophelia Lee
- 5 years ago
- Views:
Transcription
1 UEA Office Use only: Patient Indentification umber: Please try to fill in ALL parts of the questionnaire, even if you do not have sinus problems and do not feel they are directly relevant to you. The Socioeconomic Cost of Chronic Rhinosinusitis (SoCCoR) Study CRS Patient Follow-up Questionnaire Pack FOR DOCTOR TO COMPLETE: CRS WITHOUT POLYPS CRS WITH POLYPS For Office Use Only: RECRUITMET SITE JPUH QEHB COFIRMED/SUSPECTED AFRS RSCH UH COTROL GSTH FH COFIRMATIO OF DIAGOSIS WITH: Other CT SCA EDOSCOPY Other, please specify: Please return the questionnaire to the orwich Medical School, UEA, orwich - for the attention of Mr Carl Philpott Follow-up pack including follow-up v1.5p, EQ-5D and SOT-22 Page 1 of 9
2 The Socioeconmic Cost of Chronic Rhinosinusitis (SoCCoR) Study Assessment: Follow up Date: D D / M M / Y Y Y Y These questions help us to understand how your chronic rhinosinusitis (CRS) affects your use of health services and how much your chronic rhinosinusitis costs you and your family. Please read the questions carefully and tick the relevant boxes or provide information when requested. All the questions ask you how many times you have used a service or how much you have spent since your last follow-up which was on D D / M M / Y Y If you cannot remember things exactly please give your best estimate. Feel free to add any of your own notes. A) Hospital services 1. In the last 3 months, how many times have you been in hospital? because of your CRS? for other reasons? For an outpatient appointment For a daycare appointment Admitted as an inpatient Total number of ights in the last 3 months: B) Community health and social services 2. In the last 3 months, how many times have you consulted your GP? At the Surgery At home Over the telephone because of your CRS? for other reasons? 3. In the last 3 months, how many times have you consulted a nurse from your local surgery? At the Surgery At home Over the telephone because of your CRS? for other reasons? 4. In the last 3 months, have you seen any of the following HS health care professionals:? Health visitor Physiotherapist Occupational Therapist Other for your CRS? for other reasons? For each, please provide number of: surgery/practice visits home visits telephone calls Other please specify: 5. In the last 3 months, how many prescriptions have you paid for:...for CRS Total number of prescriptions for other diseases exempt from charges Page 2 of 9
3 C) Private and Alternative Healthcare For each, please provide total amount spent on treatment since last follow-up other reasons? 6. In the last 3 months, how many times have you seen a complementary therapist or alternative medicine practitioner? e.g. acupuncturist, homeopath, chiropractor, osteopath, reflexologist, naturopath? o. of Amount paid Amount paid for Type of practitioner seen (and no of times): times?: for your CRS?: other reasons?: : 7. In the last 3 months, have you paid for any private health care? Type of practitioner seen (and no of times): o. of times?: Amount paid for your CRS?: Amount paid for other reasons?: : D) Medications and equipment 8. In the last 3 months have you taken any medication prescribed by your GP or a hospital doctor? ame of medication Is this medication a 'One-off' a repeat prescription Are you taking this medication for your CRS symptoms other reasons Who recommended this medication? Hospital doctor GP Other Please specify Did this medication help to erase/improve your symptoms Yes o i ame of medication Is this medication a 'One-off' a repeat prescription Are you taking this medication for your CRS symptoms other reasons Who recommended this medication? Hospital doctor GP Other Please specify Did this medication help to erase/improve your symptoms Yes o Page 3 of 9
4 ii ame of medication Is this medication a 'One-off' a repeat prescription Are you taking this medication for your CRS symptoms other reasons Who recommended this medication? Hospital doctor GP Other Please specify Did this medication help to erase/improve your symptoms Yes o 9. In the last 3 months, have you paid for any non-prescription ("over the counter") medicines under the following categories (for any reason, not just your CRS - use approximate costs): a) Pain killers (e.g. paracetamol, aspirin) ame of product Did this medication help to erase/improve your symptoms Yes o i ame of product Did this medication help to erase/improve your symptoms Yes o ii ame of product Did this medication help to erase/improve your symptoms Yes o b) Antihistamines (e.g. cetirizine, loratadine, promethazine ) ame of product Did this medication help to erase/improve your symptoms Yes o Page 4 of 9
5 i ame of product Did this medication help to erase/improve your symptoms Yes o ii ame of product Did this medication help to erase/improve your symptoms Yes o c) Cold and 'flu remedies (e.g. 'flu powders, decongestant tablets or inhaltion remedies, cough sweets/syrups) ame of product Did this medication help to erase/improve your symptoms Yes o i ame of product Did this medication help to erase/improve your symptoms Yes o ii ame of product Did this medication help to erase/improve your symptoms Yes o d) asal sprays (e.g. beclomethasone, sinus rinses) ame of product Did this medication help to erase/improve your symptoms Yes o Page 5 of 9
6 i ame of product Did this medication help to erase/improve your symptoms Yes o ii ame of product Did this medication help to erase/improve your symptoms Yes o e) Other (e.g. vitamins & minerals) ame of product Did this medication help to erase/improve your symptoms Yes o i ame of product Did this medication help to erase/improve your symptoms Yes o ii ame of product Did this medication help to erase/improve your symptoms Yes o E) Telephone calls 10. In the last 3 months, around how many telephone calls have you made to any health or social services (excluding any you have already told us about in previous questions (2,3 & 4)? F) Days off 11. In the last 3 months, around how many days have you been off work and/or unable to perform your normal activities: because of your CRS? (days) for other reasons? (days) Page 6 of 9
7 Under each heading, please tick the OE box that best describes your health TODAY Mobility I have no problems in walking about I have slight problems in walking about I have moderate problems in walking about I have severe problems in walking about I am unable to walk about Self-Care I have no problems washing or dressing myself I have slight problems washing or dressing myself I have moderate problems washing or dressing myself I have severe problems washing or dressing myself I am unable to wash or dress myself USUAL ACTIVITIES (e.g. work, study, housework, family or leisure activities) I have no problems doing my usual activities I have slight problems doing my usual activities I have moderate problems doing my usual activities I have severe problems doing my usual activities I am unable to do my usual activities Pain/Discomfort I have no pain or discomfort I have slight pain or discomfort I have moderate pain or discomfort I have severe pain or discomfort I have extreme pain or discomfort Anxiety/Depression I am not anxious or depressed I am slightly anxious or depressed I am moderately anxious or depressed I am severely anxious or depressed I am extremely anxious or depressed EQ - 5D TM Page 7 of 9
8 We would like to know how good or bad your health is TODAY. This scale is numbered from 0 to means the best health you can imagine. 0 means the worst health you can imagine. Mark an X on the scale to indicate how your health is TODAY. ow, please write the number you marked on the scale in the box below. YOUR HEALTH TODAY: EQ - 5D TM Page 8 of 9
9 Snot - 22 Questionnaire ISTRUCTIOS: Below you will find a list of symptoms and social/emotional consequences of your nasal disorder. We would like to know more about these problems and would appreciate your answering the following questions to the best of your ability. There are no right or wrong answers and only you can provide us with this information. Please rate your problems over the last two weeks. Considering how severe the problem is when you experience it and how frequently it happens, please rate each item below on how "bad" it is by filling in the box that corresponds to how you feel. (Fill one box only per item) o Problem Very mild Mild or slight Moderate Severe As bad as it could be eed to blow nose Sneezing Runny nose asal obstruction Loss of smell or taste Cough Post-nasal discharge Thick nasal discharge Ear fullness Dizziness Ear Pain Facial pain/pressure Difficulty falling asleep Wake up at night Lack of good night's sleep Wake up tired Fatigue Reduced productivity Reduced concentration Frustrated/restless/irritable Sad Embarrassed SOT - 22 Thank you for taking part in this survey Page 9 of 9
The Socioeconomic Cost of Chronic Rhinosinusitis (SoCCoR) Study
UEA Office Use only Local Ref Please try to fill in ALL parts of the questionnaire, even if you do not have sinus problems and do not feel they are directly relevant to you. The Socioeconomic Cost of Chronic
ARTIC PC. Diagnosis & treatment study Diary. Version 1 ( )
Patient Study Number: Date of consultation: Month Year ARTIC PC Diagnosis & treatment study Diary Version 1 (09.08.16) Page 1 of 29 INSTRUCTIONS Your doctor or nurse and researchers from the ARTIC-PC study
Varicose Veins Surgery Questionnaire
REV_VaricoseVeins_12pp_Q_PostOp 29/10/09 Page 1 Varicose Veins Surgery Questionnaire After your operation About three months ago you had a Varicose Veins Operation. You may remember that you agreed that
London Pathway Evaluation
Digestive Disorders Clinical Academic Unit Endoscopy Unit The Royal London Hospital Whitechapel London E1 1BB Tel: 020 7377 7218 Main switchboard: 020 7377 7000 The Trial Homeless people, outcomes questionnaire
Shasta ENT Specialists Redding SINUS Center George H. Domb M.D. NEW PATIENT/SINUS INFORMATION. Patient Name: Date: Birth Date: M/F:
Shasta ENT Specialists Redding SINUS Center George H. Domb M.D. NEW PATIENT/SINUS INFORMATION Patient Name: Date: Birth Date: M/F: Family Doctor: Referred By: Reason for Your Visit: Below you will find
KAISER PERMANENTE SPINE
KAISER PERMANENTE SPINE The following forms are specially designed to give your doctor valuable information about the health of your spine. The same way an EKG gives us information about your heart. It
Mesothelioma Outcomes, Research and Experience survey (MORE Survey).
Mesothelioma Outcomes, Research and Experience survey (MORE Survey). Mesothelioma UK would like to invite mesothelioma patients to have the opportunity to describe what their experience of investigations,
London Pathway Evaluation
Digestive Disorders Clinical Academic Unit Endoscopy Unit The Royal London Hospital Whitechapel London E1 1BB Tel: 020 7377 7218 Main switchboard: 020 7377 7000 The Trial Homeless people, outcomes questionnaire
Please return the questionnaire in the enclosed pre-paid envelope
Instructions Please complete the questionnaire, making sure you reply to all the questions. This should take you about 20 minutes. If you have difficulties completing the questionnaire, please ask someone
KAISER PERMANENTE SPINE
KAISER PERMANENTE SPINE The following forms are specially designed to give your doctor valuable information about the health of your spine. The same way an EKG gives us information about your heart. It
Your Health Survey. Forename: Surname: Renal Unit: Type of treatment: If HD, are you: Date of birth: Home Post Code: Date completed: NHS number:
Your Health Survey Why this questionnaire You may already have heard about renal units introducing health questionnaires. The purpose of these questionnaires is to find out how your kidney disease affects
Pediatric Allergies in America: A Landmark Survey of Nasal Allergy Sufferers
Pediatric Allergies in America: A Landmark Survey of Nasal Allergy Sufferers EXECUTIVE SUMMARY Prepared for Nycomed Conducted by Schulman, Ronca and Bucuvalas, Inc. May 8, 2007 Supported by: Study Design
MRN: T C D PATIENT INFORMATION
MRN: T C D PATIENT INFORMATION Today s Patient s Date: / / Name: (First) (MI) (Last) Address: City: State: Zip Code: Home #: ( ) - Alternate #: ( ) - Work #: ( ) - Soc Sec #: - - Gender: Male Female Marital
Welcome to NHS Highland Pain Management Service
Welcome to NHS Highland Pain Management Service Information from this questionnaire helps us to understand your pain problem better. It is important that you read each question carefully and answer as
Does claritin d help with sinus pressure
Zoeken Zoeken Does claritin d help with sinus pressure May 31, 2018. If the pressure behind your nose is getting to be too painful to including neti pots and eucalyptus, that can help you get rid of sinus
Online Data Supplement Primary Ciliary Dyskinesia: First Health-related Quality of Life Measures for Pediatric Patients
Online Data Supplement Primary Ciliary Dyskinesia: First Health-related Quality of Life Measures for Pediatric Patients Sharon D Dell, Margaret W. Leigh, Jane S Lucas, Thomas W. Ferkol, Michael R. Knowles,
Sinusitis Awareness Survey May 2011
Page 1 of 5 Sinusitis Awareness Survey May 2011 Playing Doctor and Paying a Price: Sinusitis Sufferers Often Misdiagnose Themselves, Confusing Symptoms with Allergies For 35 million Americans with nasal
Welcome to the UCLA Center for East- West Medicine Primary Care
Instructions: Welcome to the UCLA Center for East- West Medicine Primary Care We ask a lot of questions because we really want to get to know you! Please take your time with the paper work and return it
Neuropathic pain (pain due to nerve damage)
Neuropathic pain (pain due to nerve damage) Clinical Guideline Pain can be nociceptive, neuropathic or mixed. The neuropathic component of pain generally responds poorly to conventional analgesics. Consider
Next page. Name MRN DOB Date. Telephone H W M. Pharmacy
University of Texas Medical School at Houston Department of Otorhinolaryngology- Head & Neck Surgery Texas Sinus Institute www.ut-ent.org New Patient Questionnaire Rev. 2014-07-19 FINAL REV Page 1 of 7
Good. Poor [ ] [ ] Yes, at all [ A ] Moderate activities, such as moving a table, pushing a vacuum cleaner, bowling, or playing golf [ ] [ ]
![Good. Poor [ ] [ ] Yes, at all [ A ] Moderate activities, such as moving a table, pushing a vacuum cleaner, bowling, or playing golf [ ] [ ]](/thumbs/96/126804246.jpg "Good. Poor [ ] [ ] Yes, at all [ A ] Moderate activities, such as moving a table, pushing a vacuum cleaner, bowling, or playing golf [ ] [ ]")
PATIENT I.D. This survey asks for your views about your health. This information will help keep track of how you feel and how well you are able to do your usual activities. For each of the following questions,
R Number. Patient Intake
Date: dd/mm/yy Patient Information Name: OHIP #: Female Male Age: Date of Birth: dd/mm/yy Phone: Address: Email: City: Postal Code: What is your current marital status? Married Common-law Single (never
Female. Separated. Non-Hispanic/Latino. Unknown
Patient Information Today s Date Patient s Legal Name Other names patient uses Male SSN - - Marital Status Single Ethnicity Hispanic/Latino Married Female Separated Non-Hispanic/Latino Date of Birth /
PREPARATION FOR ALLERGY TESTING *** Please read this information at least one week before your upcoming visit.
PREPARATION FOR ALLERGY TESTING *** Please read this information at least one week before your upcoming visit. In order to obtain valid and useful skin testing results, you will need to stop the use of
Patient Outcome Scores (pre-op)
Name: NHS No: Hospital No: DOB: Gender: Patient Outcome Scores (pre-op) Subjective Knee Evaluation Symptoms: Grade symptoms at the highest activity level at which you think you could function without significant
7. Study instruments for 13/14 year olds
7. Study instruments for 13/14 year olds 7.1 Instructions for completing questionnaire and demographic questions Examples of instructions for completing questionnaires and demographic questions are given
<</<</<<<< <</<</<<<< < << <<< * * *1* *TCO26* ! No Surgery or Treatment Scheduled Yet
Cervical Myelopathy Pre-Treatment Form - Twin Cities Orthopedics STICKER FIELD If there is not any sticker available please write the required data below: Patient First Name: Patient Last Name: Medical
Patient Scheduled Letter Thunderbird Internal Medicine Sleep Center 5620 W. Thunderbird Rd., Suite C-1 Glendale, AZ (602)
Patient Scheduled Letter Thunderbird Internal Medicine Sleep Center 5620 W. Thunderbird Rd., Suite C-1 Glendale, AZ 85306 (602) 938 6960 Dear Patient, Your Doctor has requested you be scheduled for a sleep
Comprehensive History, Consult, and Evaluation Form
1 Comprehensive History, Consult, and Evaluation Form 1.Patient Information: Today s Date: Mr. Ms. Miss Mrs. Dr. Name Age: Date of Birth: Male Female Address: City/State/Zip: Home Phone: Work Phone: Cell
Patient Details Hidden. Clinical Enrollment. Quality of Life. EuroQOL (EQ-5D) Enroll Patient. Not Started. Not Started
Patient Details Hidden Show Patient Clinical Enrollment t Started Quality of Life t Started EuroQOL (EQ-5D) Did the patient complete a EuroQOL form? Please select a reason why the EuroQOL was not completed:
If you have any difficulties in filling out the forms, please contact our team administrator on
Westminster IAPT Primary Care Psychology Service Lisson Grove Health Centre Gateforth Street London NW8 8EG Team Administrator Tel: 07971315596 Dear Sir/Madam Thank you for requesting this opt-in pack
Non Arthroplasty Hip Surgery Register (NAHR) Patient Consent Form
The Non Arthroplasty Hip Surgery Register (NAHR) Patient Sticker The British Hip Society 35-43 Lincoln s Inn Fields, London WC2A 3PN www.britishhipsociety.com/nahr Non Arthroplasty Hip Surgery Register
Pituitary Tumour Surgery. Remember to bring this handout to the hospital with you.
Pituitary Tumour Surgery Remember to bring this handout to the hospital with you. 1 Pituitary Tumour Surgery Table of contents Page What is the pituitary gland?... 2 What is a pituitary tumour?... 3 Why
PAIN SERVICE REFFERAL QUESTIONNAIRE
PAIN SERVICE REFFERAL QUESTIONNAIRE We would appreciate you taking some time to answer this questionnaire. It asks about your pain, and how your pain affects your life and this information is helpful to
Session 6: Choosing and using HRQoL measures vs Multi-Attribute Utility Instruments QLU-C10D and EQ-5D as examples
Session 6: Choosing and using HRQoL measures vs Multi-Attribute Utility Instruments QLU-C10D and EQ-5D as examples - Madeleine King & Richard De Abreu Lourenco- Overview Learning Objectives To discuss
Dear Patient, Sincerely, South Texas Bone & Joint Physical Therapy & Rehabilitation Team
Physical Therapy & Rehabilitation 601 Texan Trail, Suite 250 Corpus Christi, Texas 78411 Telephone: (361)854-0811 EXT 221 Fax: (361)561-0609 www.southtexasboneandjoint.com Dear Patient, South Texas Bone
Brief Pain Inventory (Short Form)
Brief Pain Inventory (Short Form) Study ID# Hospital# Do not write above this line Date: Time: Name: Last First Middle Initial 1) Throughout our lives, most of us have had pain from time to time (such
Anaesthesia and pain (Daycase Patient) Patient information Leaflet
Anaesthesia and pain (Daycase Patient) Patient information Leaflet February 2018 INTRODUCTION Welcome to Tameside Hospital, this leaflet gives basic information to help you prepare for your anaesthetic,
Initial Patient Questionnaire
Insert service name and logo here Initial Patient Questionnaire Section 1 Patient information Title: Family name (surname): Given name(s): Mr Mrs Ms Miss Gender: Male Female Date of birth: / / Today s
INFLUENZA (FLU) Cleaning to Prevent the Flu
INFLUENZA (FLU) Cleaning to Prevent the Flu Cleaning to Prevent the Flu 24 hours How long can the flu virus live on objects, such as doorknobs and tables? The flu virus can live on some surfaces for up
A trial to evaluate an extended rehabilitation service for stroke patients (EXTRAS) PATIENT BASELINE ASSESSMENT
A trial to evaluate an extended rehabilitation service for stroke patients () PATIENT BASELINE ASSESSMENT Version 5: 11 February 2014 Patient Name: Centre Number: date: Assessor (print name): Assessor
PATIENT INFORMATION FORM
PATIENT INFORMATION FORM "I am going to ask you a number of questions about your asthma. The set of questions is somewhat long, but I will try to move through it fairly quickly so that we can complete
Patient Demographics
M.D. INFO INSURANCE INFO PATIENT INFORMATION Patient's Name (Last, First, Middle Initial): Patient Demographics Patient's Address: City: Phone #: Home: Cell: Work: State: Zip Code: Patient Date of Birth
Medicare Annual Wellness Visit HEALTH RISK ASSESSMENT
Patient Name: Date of Birth: GENERAL HEALTH 1. How is your overall health? Excellent Good Fair Poor 2. How many different prescriptions are you taking? 0-3 4-6 7-10 10+ 3. Do you take all of your mediations
Sources. Taking Charge of Your Asthma. Asthma Action Plan (to be completed with your doctor) UnitedHealthcare Insurance Company
Asthma Action Plan (to be completed with your doctor) Green Zone: (80 to 00% of my personal best) Peak Flow between and (00% = personal best) You can do all the things you usually do. Your asthma medicine
Westminster IAPT Primary Care Psychology Service. Opt-In Questionnaire
Westminster IAPT Primary Care Psychology Service Opt-In Questionnaire In order to get a better idea of your difficulties, we would be grateful if you could complete the attached registration form and questionnaire.
Northumbria Healthcare NHS Foundation Trust. Bronchiectasis. Issued by Respiratory Medicine
Northumbria Healthcare NHS Foundation Trust Bronchiectasis Issued by Respiratory Medicine The aim of this booklet is to help you manage your bronchiectasis. It contains information which you should find
Extended Aberdeen Spine Pain Scale
Extended Aberdeen Spine Pain Scale SECTION A Please answer the following questions 1. In the last two weeks, how many days did you suffer pain in the neck, back or limbs? (Please tick one box) None at
Non-invasive ventilation (also called bi-level or BIPAP)
Patient information service Bristol Royal Infirmary Non-invasive ventilation (also called bi-level or BIPAP) Respecting everyone Embracing change Recognising success Working together Our hospitals. 2 Why
*521634* Sleep History Questionnaire. Name of primary care doctor:
*521634* Today s Date: Sleep History Questionnaire Appointment Date: Please answer the following questions before coming to your appointment. Please arrive 15 minutes early with this packet filled out.
Allina Health United Lung and Sleep Clinic
Medical History Form Date Allina Health United Lung and Sleep Clinic Name Last First MI Date of birth What lung problem do you want us to help you with: Who is your primary care provider? Social History
NASHVILLE EAR, NOSE &THROAT CLINIC STEPHEN A. MITCHELL, M.D., F.A.C.S MITCHELL K. SCHWABER, M.D. STEVEN ENRICH, M.D. MATTHEW SPEYER. M.D., P.C.
N A S H V I L L E ENT C L I N I C NASHVILLE EAR, NOSE &THROAT CLINIC STEPHEN A. MITCHELL, M.D., F.A.C.S MITCHELL K. SCHWABER, M.D. STEVEN ENRICH, M.D. MATTHEW SPEYER. M.D., P.C. WHAT TO EXPECT AFTER SEPTOPLASTY
Allergic Rhinitis. What Does Allergic Rhinitis Mean? Published on: 9 Jul 2014
Published on: 9 Jul 2014 Allergic Rhinitis What Does Allergic Rhinitis Mean? Allergic rhinitis is the way doctors describe an allergy that affects the nose. What happens when you have an allergy? To understand
4. How often do you use all of your energy to accomplish only this activity? [yellow card]
![4. How often do you use all of your energy to accomplish only this activity? [yellow card]](/thumbs/96/127246568.jpg "4. How often do you use all of your energy to accomplish only this activity? [yellow card]")
Calgary Sleep Apnea Quality of Life Index (Interviewer) This questionnaire has been designed to find out how you have been doing and feeling over the last 4 weeks. You will be questioned about the impact
PATIENT SLEEP QUESTIONNAIRE
PATIENT SLEEP QUESTIONNAIRE Name: Date of Birth: Today s Date Primary Care Physician Telephone # Physician ordering test (Other than PCP): Physician s Tel. #: _ Age: Years Height: Feet Inches Weight: Lb
QOLRAD QUESTIONNAIRE FOR PATIENTS WITH GASTROINTESTINAL SYMPTOMS PLEASE READ THIS CAREFULLY BEFORE ANSWERING THE QUESTIONS
QOLRAD QUESTIONNAIRE FOR PATIENTS WITH GASTROINTESTINAL SYMPTOMS PLEASE READ THIS CAREFULLY BEFORE ANSWERING THE QUESTIONS On the following pages you will find some questions asking about how you have
Disease Modifying Anti-Rheumatic Medications (DMARDS) Monitoring Clinic
Department of Rheumatology Portsmouth Hospitals NHS Trust Disease Modifying Anti-Rheumatic Medications (DMARDS) Monitoring Clinic Patient Information Leaflet Specialist Support This leaflet can be made
If you arrive at the office without these forms, your visit may need to be rescheduled.
Dear, Your Appointment for the Welcome to Medicare Visit OR Annual Wellness Visit is scheduled on at There is NO CO-PAY for this visit, so it is free for you. The goal of this visit is to provide time
PATIENT QUESTIONNAIRE Boise Location 7272 W. Potomac Drive Boise, ID (208)
PATIENT QUESTIONNAIRE Boise Location 7272 W. Potomac Drive Boise, ID 83704 (208)884-2922 ***Questionnaire MUST be completed PRIOR to arrival for appointment*** Today s Date / / / / Last First MI DOB Referring
TRIPROLIDINE. Please read this leaflet and the packaging of the medicine you purchased, carefully before you start using triprolidine.
TRIPROLIDINE New Zealand Consumer Medicine Information What is in this leaflet The medicine you have purchased contains triprolidine. This leaflet is intended to provide information on the active ingredient
Standardised Data Collection Questionnaire Patient Information Version 2.0 SDC
Standardised Data Collection Questionnaire Patient Information Version 2.0 SDC Part 1: Initial consultation for new episode To be completed by the osteopath Practitioner ID code 1. Date of first appointment
RETURNING PATIENT HEALTH QUESTIONNAIRE ADULT DOWN SYNDROME CENTER ADVOCATE LUTHERAN GENERAL HOSPITAL
RETURNING PATIENT HEALTH QUESTIONNAIRE Date of Appointment ALL QUESTIONS REFER TO THE PERSON WITH DOWN SYNDROME Name Date of Birth Person Filling Out the Form: Do you have any specific concerns regarding
NPM INTAKE FORM: ADULT INFORMATION: Name: Age: Date:
NPM INTAKE FORM: ADULT INFORMATION: Name: Age: Date: Address: City/State/Zip: Home Phone No.: Work Phone No: Cell Phone: Email Address: Gender: Date of Birth: Occupation: Best Time to Contact: Number of
NPM INTAKE FORM. INFORMATION: Name: Age: Date: Home Phone No.: Work Phone No: Cell Phone: Address:: Gender: Date of Birth:
NPM INTAKE FORM INFORMATION: Name: Age: Date: Address: City/State/Zip: Home Phone No.: Work Phone No: Cell Phone: Email Address:: Gender: Date of Birth: Occupation: Best Time to Contact: Number of Children
NPM INTAKE FORM INFORMATION: Name: Age: Date:
NPM INTAKE FORM INFORMATION: Name: Age: Date: Address: City/State/Zip: Home Phone No.: Work Phone No: Cell Phone: Email Address:: Gender: Date of Birth: Occupation: Best Time to Contact: Number of Children
Your Medicine: Be Smart. Be Safe.
Your Medicine: Be Smart. Be Safe. Learn more about how to take medicines safely. Use the wallet card at the back of this booklet to keep track of your medicines. Keep this booklet with your medicines and
If you wake up to urinate 2 or more times a night, ask your doctor about NOCTIVA
If you wake up to urinate 2 or more times a night, ask your doctor about NOCTIVA IMPORTANT SAFETY INFORMATION WARNING: HYPONATREMIA See full prescribing information for complete boxed warning. NOCTIVA
Persistent Pain Management Service eppoc Initial Questionnaire
Persistent Pain Management Service eppoc Initial Questionnaire URN: Family name: Given name(s): Date of Birth: Section 1 Your details Title Mr Mrs Family name (surname) Given name(s) Ms Miss Gender Male
Flu. is a killer. If you are at risk you should have your free flu vaccination every year.
Flu is a killer. If you are at risk you should have your free flu vaccination every year. What is flu? Flu spreads easily and can cause serious illnesses which need to be treated in hospital. It is not
Excellence in Care: Over-the-Counter Drugs Update Emphasis on Pediatrics 2012
Excellence in Care: Over-the-Counter Drugs Update Emphasis on Pediatrics 2012 Renee Acosta, RPh INDEPENDENT STUDY Health Professions Institute Continuing Education Austin Community College The Austin Community
Functional Endoscopic Sinus Surgery
WHAT IS FUNCTIONAL ENDOSCOPIC SINUS SURGERY (FESS)? The nasal telescope has greatly changes the evaluation and treatment of rhino-sinusitis. This instrument, which provides a view of the structures in
Patient & Family Guide. Norovirus. Aussi disponible en français : Norovirus (FF )
Patient & Family Guide Norovirus 2017 Aussi disponible en français : Norovirus (FF85-1855) www.nshealth.ca Norovirus What is norovirus? Norovirus is a common fall and winter virus. Some people may refer
Has Consumer Directed Care improved the quality of life of older Australians? Professor Julie Ratcliffe School of Medicine Flinders University
Has Consumer Directed Care improved the quality of life of older Australians? Professor Julie Ratcliffe School of Medicine Flinders University Acknowledgments: ARC Linkage Project A Health Economics Model
Cold, Flu, or Allergy?
A monthly newsletter from the National Institutes of Health, part of the U.S. Department of Health and Human Services October 2014 Cold, Flu, or Allergy? Know the Difference for Best Treatment You re feeling
Jeffrey E. Lazarus, M.D. Board Certified in Pediatrics Child & Adolescent Clinical Hypnosis & Biofeedback. Headache Questionnaire
Jeffrey E. Lazarus, M.D. Board Certified in Pediatrics Child & Adolescent Clinical Hypnosis & Biofeedback 1220 University Drive, Suite 104 Menlo Park, California 94025 www.jefflazarusmd.com Headache Questionnaire
Please fill out the following form in as much detail as possible. Please Print. Name. Address. City State Zip. Home Phone Office Phone.
CASE NO. Please fill out the following form in as much detail as possible. Please Print Date Name Address City State Zip Home Phone Office Phone E-mail Address Age Date of Birth Occupation Sex (M) (F)
Mastoidectomy or combined approach tympanoplasty
PLEASE PRINT WHOLE FORM DOUBLE SIDED ON YELLOW PAPER Patient Information to be retained by patient affix patient label What is a cholesteatoma? This is a cyst of skin cells behind your eardrum. As it gets
In order to receive the maximum benefit from your rehabilitation program, it is important to understand and comply with the following guidelines:
Arrival Policy 900 2 nd Ave., Madison, MN 56256 In order to receive the maximum benefit from your rehabilitation program, it is important to understand and comply with the following guidelines: Attend
Sinusitis. What are the sinuses? Who develops sinusitis?
Sinusitis Health experts estimate that 37 million Americans are affected by sinusitis every year. Americans spend nearly $6 billion each year on health care costs related to sinusitis. Sinusitis is an
MY TRACKING DIARY. MY Tracking. Diary TAKING ACTION AGAINST EPILEPSY
MY TRACKING DIARY MY Tracking Diary TAKING ACTION AGAINST EPILEPSY CONTACT INFORMATION PERSONAL Name: Phone: Email: MAIN CAREGIVER/COMPANION Name: Phone: Email: FAMILY PHYSICIAN Name: Phone: Email: TABLE
General Questionnaire
General Questionnaire Name: Date: Address:_ Home Phone: Alternate number: Occupation: Age: Height: Weight: Weight 6 months ago: At age 20: At your heaviest: Referring Physician: Family Physician: 1. In
Food for thought. Department of Health Services Research 1
Food for thought Suppose you have been asked to undertake an economic evaluation of the costs and effects on the Fall prevention program Identify the range of different costs that you might wish to include
Does claritin help chest congestion
Search Search Does claritin help chest congestion Nasal congestion, commonly known as a stuffy nose, congested nose, or stopped-up nose, is a common health problem that affects millions of people. 8-9-2010
How to Exercise with CFS
How to Exercise with CFS To equip people affected by CFS / ME with the skills for self-management towards a better quality of life. Adult CFS / ME Service January 2018 Review January 2019 HOW CAN I EXERCISE
Cystometrogram (Urodynamic Studies)
Who can I contact if I have a problem when I get home? If you experience any problems related to your surgery or admission once you have been discharged home. Please feel free to contact 4A, 4B or 4C ward
Canalplasty / excision of exostoses
PLEASE PRINT WHOLE FORM DOUBLE SIDED ON YELLOW PAPER Patient Information to be retained by patient affix patient label What is a canalplasty? A canalplasty is an operation to remove exostoses, which are
In case of an urgent concern or emergency, call 911 or go to the nearest emergency department right away.
Asthma Basics Patient and Family Education This teaching sheet contains general information only. Talk with your child s doctor or a member of your child s healthcare team about specific care of your child.
Patient & Family Guide. Nose Surgery.
Patient & Family Guide Nose Surgery 2017 www.nshealth.ca Nose Surgery Types of nose surgery Nasal polypectomy Removes polyps (pale, grey swellings that may interfere with breathing). Septoplasty Repairs
This is a repository copy of Health-related quality of life after treatment for bladder cancer in England.
This is a repository copy of Health-related quality of life after treatment for bladder cancer in England. White Rose Research Online URL for this paper: http://eprints.whiterose.ac.uk/130368/ Version:
Diagnosis and Treatment of Respiratory Illness in Children and Adults Guideline
Member Groups Requesting Changes: Lakeview Clinic Marshfield Clinic Mayo Clinic South Lake Pediatrics Response Report for Review and Comment January 2013 Diagnosis and Treatment of Respiratory Illness
Influenza. What Is Influenza?
Flu is usually a mild, but uncomfortable disease. You can treat it yourself by staying home and drinking plenty of fluids. What Is?, often just called the flu, is the most common disease in the world,
The National Council for Osteopathic Research, SDC Version 2.0 Page 1
SDC Data Collection Tool Part 1: Initial consultation for new episode To be completed by the osteopath Practitioner ID code 1. Date of first appointment 2. Sex: Male Female 3. Postcode: Please state first
PULMONARY MEDICINE PATIENT QUESTIONNAIRE
PULMONARY MEDICINE PATIENT QUESTIONNAIRE Date Name DOB Age Referring Physician What problem brings you to see us today? Have you had any of the following? (Any left blank will be reported in your medical
What is an Upper GI Endoscopy?
What is an Upper GI Endoscopy? An upper GI endoscopy is a test your doctor does to see inside part of your digestive system. Your doctor will look at the inside of your esophagus (the tube that links your
PATIENT REGISTRATION PERSON TO NOTIFY IN CASE OF EMERGENCY. Name: Relationship: Phone:
PATIENT REGISTRATION Patient's Name (Last, First, MI): Date Date of Birth: Age: Sex: M / F Social Security Number: Address: Apt. # City: State: Zip: Home Number: Mobile Number: Work Number: PERSON TO NOTIFY
PARTICIPANT DIARY TREATMENT ALLOCATION: LACTIC ACID GEL
PARTICIPANT DIARY TREATMENT ALLOCATION: LACTIC ACID GEL For site staff completion only: Participating Site: Participant Initials: Participant ID: Date of Randomisation: Allocated Treatment: Lactic Acid
PARTICIPANT DIARY TREATMENT ALLOCATION: ORAL METRONIDAZOLE TABLETS
PARTICIPANT DIARY TREATMENT ALLOCATION: ORAL METRONIDAZOLE TABLETS For site staff completion only: Participating Site: Participant Initials: Participant ID: Date of Randomisation: Allocated Treatment:
Instructions. If you make a mistake, put an "X" over the checkmark. Then put a checkmark in the correct box and draw a circle around that box.
SLEEP HEART HEALTH STUDY SLEEP HABITS AND LIFESTYLE QUESTIONNAIRE Instructions Thank you for taking time to fill out the enclosed Sleep Habits Questionnaire. Please fill out the form completely. You may
Pro Active Physical Therapy & Sports Medicine
Pro Active Physical Therapy & Sports Medicine Consent and Statement of Financial Responsibility 1. CONSENT FOR TREATMENT: I consent to and authorize my physical therapist, occupational therapist and other