WORKPLACE ASSESSMENTS STUDENT INFORMATION SIR30112 Certificate III in Community Pharmacy
|
|
|
- Vernon Adams
- 5 years ago
- Views:
Transcription
1 WORKPLACE ASSESSMENTS STUDENT INFORMATION SIR30112 Certificate III in Community Pharmacy As you are aware you are enrolled in the above qualification through your position with the My Chemist Warehouse Group. You will have attended Induction classroom training and also have been completing your online Product Knowledge training as well. As a Nationally Registered Training Organisation Dillon Whitelaw is required to assess students in all aspects of the qualification and units of competence they are undertaking. This includes an assessment of your skills and knowledge which is undertaken two ways, through the online test and workplace assessments with one of our qualified assessors observing you completing normal workplace tasks. A workplace assessment in this qualification will normally include the observation of selling products to customers or undertaking role plays with your assessor when this is not possible, which is a core component of the role of a pharmacy assistant. This will also include the sale of scheduled products which is known as S2S3 and is a compliance requirement for the Quality Community Pharmacy Program. There are a standard set of requirements for these workplace assessments and to prepare for your workplace assessment you should practise the following: 1. Asking the Safety 7 questions to identify if the sale requires a referral to the pharmacist-see further information over the page 2. Knowing what responses, the customer provides from the Safety 7 questions, that require you to refer to the pharmacist 3. Following and relaying instructions from the Pharmacist to give to the customer 4. Providing important product information on how to use the products, possible side effects and how long the product can be safely used for. This means that you need to know the products you are selling, what schedule they fall under and when you need to refer a sale to the pharmacist. The best way to ensure you are fully prepared for a workplace assessment is: 2016 Students - Read the S2S3 Info Pack you received at Induction along with the Fast Facts sheet you were also given Students-review your online S2S3 Notes Review your Online Product Knowledge You can do this by selecting the different modules and downloading the PDF to read. If you have previously completed all of your online learning you will be enrolled in the Continuing Education program and can access the notes there. Go to the Certificate 3 Product Knowledge Review section where you will find PDF versions of the product knowledge units for the previous 12 months. Try to ensure you are rotated within the store so that you can gain experience in selling different products and questioning customers
2 Ask the instore pharmacist for information on different products you are uncertain about. Our assessor will normally role play these assessments with you to ensure you are fully prepared and have the knowledge and skills you need before observing you in action serving customers. It is important that you are consistent in demonstrating your skills over a number of sales and must always ask the Safety 7 questions to successfully complete these workplace assessments. We understand and allow for nerves and you are given several attempts to correctly demonstrate the tasks. If you are unable to satisfactorily demonstrate the tasks at this visit you will be reassessed at a later time. All instore workplace assessments are arranged with your Store Manager based on your normal working roster and we always try not to remove you from the floor if at all possible. SAFETY 7 QUESTIONS TO ASK THE CUSTOMER 1. Is this product for you?- ** for all women of child bearing age-are you pregnant, breastfeeding or planning to become pregnant? **If the customer is a child what is their age? 2. What are your symptoms? 3. What have you tried already? 4. Are you taking any other medicines, vitamins or supplements? 5. Do you have any medical conditions? 6. Have you used this product before? 7. Do you have any allergies or intolerances to any food or medicines? If you have any questions about your training or workplace assessment please contact us via at admin@dillon.com.au or call us on (03)
3 SKILLS AND KNOWLEDGE TO REVIEW FOR INSTORE ASSESSMENT If you have received an SMS in relation to your assessment, refer to the Codes in the SMS to see what you need to review from the assessment types below. S2S3 - S2S3 Workplace Observation Information on scheduling Location and examples of Schedule2 and Schedule3 You will be observed supplying three customers with behind the bar medications, asking the safety 7 questions and referring to the pharmacist if necessary. It may take place in the form of role-plays with the assessor instead. A discussion on dealing with difficult customers SAFETY - Safety Workplace Observation Please review information on My Web about workplace health and safety (WHS) policies and procedures for the My Chemist Warehouse group Location of WHS equipment and procedures- including emergency evacuations, fire extinguishers, cleaning materials, first aid kit, waste disposal and incident reporting Understanding of potential hazards in the store and how you would deal with them Knowledge of correct manual handling skills RETAIL - Retail Workplace Observation You will be observed serving three customers at the registers and completing their transactions Understanding of how to deal with a customer complaint Understanding of how to answer and use the telephone, including doing a special order for a customer over the phone Knowledge of workplace documentation- including rosters, policies and procedures, awards and using the My Web staff portal MERCH - Merchandising Workplace Observation Please review information on My Web about merchandising policies and procedures for the My Chemist Warehouse group You will be observed stocking shelves and displaying merchandise, taking suitable action with stock discrepancies, out of date and short dated stock You will be observed using electronic ticketing equipment to prepare appropriate tickets and labels Knowledge of the store s security procedures DIS301-Accept Prescriptions and Return Dispensed Medicines to Customers Workplace Observation Please ensure you have had some practice and experience working at the scripts in/out counter in your pharmacy You will be observed accepting three different types of scripts from customers and returning prescribed medicines to customers in your pharmacy
4 INF - Comply with Infection Control Policies and Procedures Workplace Observation Understanding of how to safely clean and deal with spills that may occur in the pharmacy 205 -Cough and Cold Workplace Observation- review products for the following Runny or blocked nose Cough Headache Fever Red and watery eyes Sore throat Sneezing Tiredness 206 -Skin and Fungal Workplace Observation- review products for the following Athlete s foot Tinea Ringworm Jock itch Fungal nail infection Eczema Psoriasis Dandruff Acne Sunburn 310 -Analgesic and Anti-Inflammatory Workplace Observation- review products for the following Tension headache Migraine Muscle pain Back pain Toothache Period pain Fractured limb- it has been treated, but is in pain Nerve pain Arthritis Sprains
5 308 -Gastro-intestinal Workplace Observation- review products for the following Irritable bowel syndrome Worms Diarrhoea Constipation 304 -Smoking Cessation Workplace Observation- review products for the following General information on smoking Smoking cessation lozenges Smoking cessation patches Smoking cessation tablets Smoking cessation gums Smoking cessations inhalers 203 -First Aid and Wound Care Workplace Observation- review products for the following Sprains Broken bones Cuts Burns Bruising Infections You should also be able to demonstrate how to dress a simple cut, explaining the different types of wound dressings and their uses and select the correct bandage for the wound Asthma Management Workplace Observation- review products for the following Shortness of breath Wheezing A dry, irritating and continual cough Inhalers Spacer devices Child and adult masks Peak flow meters Infant Care Workplace Observation- review products for the following Baby formula Teat and bottle features and selection Steriliser kits Nappies and related products Rash and other skin treatments Teething products
6 309 - Allergies Workplace Observation- review products for the following Hay fever symptoms- sneezing, runny nose etc Rash Itchy and/or watery eyes Stings and bites Eye and Ear Care Workplace Observation- review products for the following Conjunctivitis Dry eyes Otitis externa (swimmer s ear) Foreign bodies in the eye Stye Ear wax impaction Otitis media Tinnitus Hearing loss Infection from ear piercing Contact lens products Continence Management Workplace Observation- review products for the following Urine incontinence Faecal incontinence Skin problems Sexual Health Medicines and Products Workplace Observation- review products for the following Pre-menstrual syndrome Erectile dysfunction Side effects of menopause- hot flushes, mood swings, reduced libido etc Pregnancy tests Ovulation testing kits Pelvic floor weakness Vaginal thrush STD prevention Pregnancy prevention
7 201 - Commonly Requested Vitamins, Minerals and Supplements Workplace Observationreview products for the following Fatigue Anaemia Weight loss Arthritis Osteoporosis Dry skin Vitamin/mineral deficiency Pregnancy multivitamin Urinary tract infections Complimentary medicines Workplace Observation- review products for the following Echinacea Glucosamine Probiotics Ginger St John s Wort Valerian Propolis
Prescribing of over the counter medicines is changing
Prescribing of over the counter medicines is changing NHS England held a consultation on some changes to prescribing medication you can buy over the counter. This medication can be bought over the counter
Prescribing medicine for minor illnesses. Consultation. Information booklet
Prescribing medicine for minor illnesses Consultation Information booklet Every year, there are a lot of GP appointments for illnesses people can treat by themselves, without having to see a doctor. People
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
Medical History Form
Medical History Form Full Name Title: Mr/Mrs/Ms/Miss Address Date of Birth Date Telephone: Mobile: Email: How did you hear about the Garden of health? G.P s Name and Address Are you currently seeing your
What do you believe is causing your most important health concern?
Intake form Name Today s Date Date of Birth Address City Phone Postal Code Email Primary Health Care Provider Emergency Contact Phone Note: By providing your email address you are giving us consent to
Treating minor conditions
Treating minor conditions Think Pharmacist THE BEST OF HEALTH FOR WEST SUFFOLK Treating minor conditions Minor conditions are generally not a serious health problem and can be treated with Over The Counter
self care what is self care? caring a pack to start conversations... THE NHS SAYS But can it mean more? mental wellbeing minor ailments
self care In Dudley borough mental wellbeing what is self care? THE NHS SAYS minor ailments long term conditions caring role of professionals Self care is about keeping fit and healthy, understanding when
! 30 E Padonia Rd, #305, Timonium, MD Phone: (410) Fax: (443)
! 30 E Padonia Rd, #305, Timonium, MD 21093 Phone: (410) 560-7404 Fax: (443) 705-0228 Email: info@waynebonliemd.com Today s Date: Patient Information Name: DOB: / / Address: City/Town: State: Zip: Home
Enquiry Severity Immediate or other. Joint or muscle pain - any part of the body. Abdominal pain Acute Non-acute. Acne Anxiety Acute Non-acute
We operate a hybrid triage system offering a mixture of telephone consultations, on the day emergency consultations with a doctor or pre bookable (3 days in advance) GP / Nurse Practitioner appointments
Medicines for Self Care Policy
Document purpose This policy describes the commissioning decision for medicines for self-care made by NHS Mansfield and Ashfield CCG and NHS Newark and Sherwood CCG. Version Version 1.0 Final Title Associated
Please have your health insurance card(s), a valid picture ID, and any applicable copayment ready when you check-in.
Please have your health insurance card(s), a valid picture ID, and any applicable copayment ready when you check-in. We have enclosed a questionnaire for you to complete and bring to the visit. Please
Scottsdale Family Health
Please list pharmacy you would like us to use for your medications. Pharmacy Phone Number Fax Number Since your last visit: 1. Have you been diagnosed with any new medical conditions? Yes No If Yes (give
l.com The gy or foodintol COPYRIGHT: Copyright of the
The Symptoms Matrix Symptoms of Food Allerg gy or Food Intolerance foodintol : The foodintol Trademark is a Registered Trademark of No Whey Pty Ltd ABN 37 644 931 517 COPYRIGHT: All publications are protected
Symptom Review (page 1) Name Date
v2.4, 2/13 JonathanTreasure.com Botanical Medicine & Cancer Herb Drug Interactions Herbalism 3.0 Symptom Review (page 1) Name Date INSTRUCTIONS Please read each section below carefully and, after each
New Life Allergy Treatment Centre Your Natural Solution to Health New Patient Health History
New Life Allergy Treatment Centre Your Natural Solution to Health New Patient Health History Name PH#(home) Cell Address City Province Postal Code Date of Birth D/M/YY Age Gender Email address Do you exercise?
Form.NewPatientHstory_PrecisionEndoRev Page 1 of 5
Patient s Name (First, Middle, Last): Address: City: State: Zip Code: Email: Main Contact#: Alternate#: Work#: Date of Birth: / / Sex: Male Female SS# (optional): Marital Status : Single Married Divorced
Candida Questionnaire: Are your health problems yeast connected?
Candida Questionnaire: Are your health problems yeast connected? The following questionnaire can be given to your clients if you suspect candida is a problem. YES NO Have you taken repeated courses of
Pediatric Intake Form
Patient Name DOB Pediatric Intake Form 1 Pediatric Intake Form Welcome. Our philosophy and approach to medicine is wholistic and seeks to understand all factors that may be affecting your health. This
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:
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
Pemetrexed APOTEX Powder for Injection Contains the active ingredient pemetrexed (as disodium)
Pemetrexed APOTEX Powder for Injection Contains the active ingredient pemetrexed (as disodium) Consumer Medicine Information For a copy of a large print leaflet, Ph: 1800 195 055 What is in this leaflet
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
Silver Child Development Center New Patient Questionnaire. Relation (circle) Biological Mother Stepmother Adoptive Mother
Silver Child Development Center New Patient Questionnaire Today s Date Mother s Name First Last Date of Birth Relation (circle) Biological Mother Stepmother Adoptive Mother Foster Mother Other Father s
Section A: History. 1. Have you taken tetracyline (Sumycin, Panmycin, Vibramycin, Minocin, etc.) or other antibiotic for acne for 1 month or longer?
CANDIDA QUESTIONNAIRE DR WENDY WELLS, NMD The total score will help you and your physician decide if your health problems are yeast-connected. ** Yeast-connected health problems are almost certainly present
New Life Allergy Treatment Center
New Life Allergy Treatment Center Your Natural Solution to Health New Patient Health History Name Ph#(home) (cell) Address City State Zip Code Date of Birth D/M/Y Age Gender Email Address Do you exercise?
Eastern Body Therapy
2310 Eastern Body Therapy 6th Avenue San Diego, CA 92101 (619)772-4002 Personal Information Name Date of injury/illness Address: Apt. City State Zip Home phone: ( ) Work Phone: ( ) E-mail: Social Security
/ / - - / / Age: USF Cutaneous Oncology Program. Skin Cancer Questionnaire. Patient Information: Fax completed forms to:
Page 1 of 8 Patient Information: Last Name: First Name: Initial: Address: Address (cont.) : City: State: Zip Code: Phone: - - Social Security Number: Date of Birth: - - Age: Sex: Female Male Email Address:
PRIMARY CARE (719)
PRIMARY CARE (719) 522-1133 Please help us in meeting your health care needs by providing the following information. *Children under 13, please use Pediatric Health History only. Thank you! Patient: Who
Laser Vein Center Thomas Wright MD Page 1 of 4
Demographics Laser Vein Center Thomas Wright MD Page 1 of 4 Patient Name: Address: City, St, Zip Primary Phone: Alternate: DOB: Social Security #: Insurance Information Primary Insurance ID# Group# Subscriber
ALLERGY CLINIC-PATIENT QUESTIONNAIRE NAME: DOB: TODAY S DATE:
ALLERGY CLINIC-PATIENT QUESTIONNAIRE NAME: DOB: TODAY S DATE: A. Please check any of the following problems which you have had, and record when they started: Problem/Date of Onset sniffles nasal congestion
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
Your Name: Date of Birth: Age: Address: City/State/Zip: Phone (home): (mobile): (work): Shall we add you to our e-newsletter?
Your Name: Date of Birth: Age: Address: City/State/Zip: _ Phone (home): (mobile): (work): Email: Shall we add you to our e-newsletter? Y / N Your Employer: Employer Phone: Employer Address: Your Occupation:
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:
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
Introduction to Vibrational Balancing Images by Kat Miller
3-Mar-10 VBI Introduction www.hc.ehdef.com Page 1 of 8 Introduction to Vibrational Balancing Images by Kat Miller Vibrational Balancing Images are images that transmit vibrations for balancing and healing
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
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
28-DAY CLEANSE GUT C.A.R.E. by Dr. Vincent Pedre. Pre-Program Medical Symptoms Questionnaire
28-DAY CLEANSE HAPPY GUT GUT C.A.R.E. by Dr. Vincent Pedre Pre-Program Medical Symptoms Questionnaire NAME ADDRESS EMAIL PHONE RATE EACH OF THE FOLLOWING SYMPTOMS BASED UPON HOW YOU HAVE FELT OVER THE
Questionnaire for Lipedema Patients
Questionnaire for Lipedema Patients Name Date of diagnosis Date Name of physician making diagnosis Do you also have lymphedema? What areas of the body are affected? Outside of thighs Inner thighs Knees
Dr. William Crook s. Candida Questionnaire
Dr. William Crook s Candida Questionnaire Candida Albicans is a yeast infection, both digestive and systemic. Literally millions of men and women have a potential yeast infection that are causing a significant
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:
NORTHWEST PROFESSIONAL OBSTETRICS & GYNECOLOGY, LTD. GYNECOLOGIC INTAKE AND HISTORY FORM
NORTHWEST PROFESSIONAL OBSTETRICS & GYNECOLOGY, LTD. GYNECOLOGIC INTAKE AND HISTORY FORM Today s Date: Name: Date of Birth: Race: American Indian or Alaskan Native Asian Black or African-American More
Name: Date of birth: Address: City: State: Zip: Phone: (day) (evening): (cell): address: Occupation: Who referred you/how did you hear about us?
Name: Date of birth: Address: City: State: Zip: Phone: (day) (evening): (cell): Email address: Occupation: Who referred you/how did you hear about us? Your primary health care provider: Phone: Emergency
MenoChat. City State Zip Code. Employer Job Title. Primary Care Provider Phone: History. Desired Outcome:
MenoChat Patient Health History Questionnaire Patient Name (last, first, MI): How did you hear of MenoChat? Address City State Zip Code Home Phone #: Cell Phone #: Male or Female Marital Status Email Employer
Pharmacy Prep. Qualifying Pharmacy Review
Pharmacy Prep 2014 Misbah Biabani, Ph.D Director, Tips Review Centres 5460 Yonge St. Suites 209 & 210 Toronto ON M2N 6K7, Canada Luay Petros, R.Ph Pharmacy Manager, Wal-Mart, Canada 1 Disclaimer Your use
The information you provide us will greatly help us provide the highest quality and most comprehensive care for you.
Rheumatology (circle location of appointment) 111 Hundertmark Rd. Suite 115N 560 S. Maple St. Suite 400 place patient label here Chaska, MN 55318 Waconia, MN 55387 952-361-2450 952-361-2450 The information
PATIENT REGISTRATION PATIENT NAME: DOB: SS#: CITY: STATE: ZIP: CELL PHONE: EMPLOYER: EMPLOYER PHONE: ( ) EMERGENCY CONTACT PH# ( ) RELATIONSHIP:
PATIENT NAME: DOB: SS#: NAME OF PARENTS (if patient is a minor) PATIENT REGISTRATION HOME ADDRESS HOME PHONE: CITY: STATE: ZIP: CELL PHONE: MAILING ADDRESS (if different) CITY: STATE: ZIP: EMPLOYER: EMPLOYER
Shiatsu Intake Form PURCHASED PRODUCT/SERVICE. Date of Birth Age Height Weight. Home Address City State ZIP
Shiatsu Intake Form DATE PURCHASED PRODUCT/SERVICE FIRST NAME LAST NAME Date of Birth Age Height Weight Home Address City State ZIP Home Phone Cell Phone Email Name of Emergency Contact Would you like
Candida Questionnaire
Candida Questionnaire The total score will help you and your physician decide if your health problems are yeast connected. Scores in women will run higher, as seven items in the questionnaire apply exclusively
Student Medical Contact and Emergency Information ALL students annually (included in enrollment packet)
2014-2015 Student Medical Contact and Emergency Information ALL students annually (included in enrollment packet) Student s Legal Name: Date of Birth (mm/dd/yyyy): Grade: Persons will be contacted in order
New Patient Form. Patient Demographics. Emergency Information. Employment Information. Page 1 of 7. Family Health Chiropractic Care
Page 1 of 7 Patient Demographics First Name* Last Name* Date Of Birth* Home Phone* Mobile Phone Phone Gender* Email Preferred Communication Street Address 1* Street Addresss 2 Zip* City* State* Emergency
General Hints when providing food at events
General Hints when providing food at events If you are providing food and the provision of that food is not for profit, part of a raffle or part of any private arrangements, it is possible to cook the
Name Age Date. Address Phone. Name of Physician. Address Street Address City State Zip Code
Name Age Date Address Phone What is the reason for your visit today? Where have you been receiving your medical care? Name of Physician Address Street Address City State Zip Code PAST MEDICAL HISTORY:
Past Medical History. Chief Complaint: Patient Name: Appointment Date: Page 1
Appointment Date: Page 1 Chief Complaint: (Please write reason, symptoms, condition or diagnosis that prompts your appointment) Past Medical History PERSONAL SKIN HISTORY YES NO Yes - Details Melanoma
Laser Vein Center Thomas Wright MD RVT Page 1 of 4
Demographics Laser Vein Center Thomas Wright MD RVT Page 1 of 4 Patient Name: Address: City, St, Zip Primary Phone: Alternate: DOB: Social Security #: Marital Status: Married Single Other Emergency Contact:
Otezla (apremilast) film coated tablets
New Zealand Consumer Medicine Information Otezla (apremilast) film coated tablets WHAT IS IN THIS LEAFLET This leaflet answers some common questions about Otezla. It does not contain all the available
Patient Name: Date: Address: Primary Care Physician: Online Website On TV In print On the radio
927 W. Myrtle St. Boise, ID 83702 (208) 947-0100 NEW PATIENT INTAKE Patient Name: Date: Email Address: Primary Care Physician: How did you hear about AVT? (Please mark all that apply) Online Website On
PATIENT INFORMATION LEAFLET CARZIN XL
SCHEDULING STATUS: S3 PROPRIETARY NAME, STRENGTH AND PHARMACEUTICAL FORM: 4 mg film coated tablets. Read all of this leaflet carefully before you start taking. Keep this leaflet. You may need to read it
Getting started with PROMACTA (eltrombopag)
Getting started with PROMACTA (eltrombopag) Indications PROMACTA is a prescription medicine used to treat adults and children 1 year and older with low blood platelet counts due to chronic immune (idiopathic)
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
For the Patient: Paclitaxel Other names: TAXOL
For the Patient: Paclitaxel Other names: TAXOL Paclitaxel (pak'' li tax' el) is a drug that is used to treat many types of cancer. It is a clear liquid that is injected into a vein. Tell your doctor if
CECILIA P MARGRET MD PhD MPH Child, Adolescent and Adult Psychiatry NE 24th ST Suite 104, Bellevue WA 98007, Phone / Fax: +1 (425)
IDENTIFYING INFORMATION PATIENT INFORMATION FORM Patient's Name: DOB: Ethnicity/race: Gender: Primary language if other than English: Address: Phone: Home/ Mobile/ Work Email: Occupation: Marital Status:
Head and Chest. Back and Stomach. Muscles and Joints. Skin. General Symptoms. Women s Health
Head and Chest Back and Stomach Muscles and Joints Skin General Symptoms Women s Health How to Use the Symptom Evaluation Charts The symptom evaluation charts are part of the Self-care Program. If you
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
Have you ever been diagnosed with any of the following? The patient has a history of the following conditions: Glaucoma
PALMETTO PHYSICAL MEDICINE 10 FINANCIAL BOULEVARD ANDERSON, SC 29621 PHONE (864) 437.8930 FAX (864) 309.8004 Have you ever been diagnosed with any of the following? Palpitation/Flutter Feelings Edema/Swelling
Chiropractic Patient Admittance Form
Chiropractic Patient Admittance Form PERSONAL INFORMATION Last Name: Given Name: Initial: Address: City/Province: Postal Code: Home Phone: Work Phone: Cell: E-mail Address: Date of Birth (D/MM/YYYY): Male
MEDICAL QUESTIONNAIRE (female)
MEDICAL QUESTIONNAIRE (female) Slievemore Clinic, Old Dublin Road, Stillorgan, Co. Dublin. Tel 01-2000501 The appointment comprises of a discussion about this questionnaire and a subsequent medical examination.
Mast Cell Activation Syndrome
Mast Cell Activation Syndrome Clinical Questionnaire Description Today s Date: Patient Name: Please indicate yes or no for the following symptoms and traits: (If you are not familiar with a particular
NEW PATIENT INTAKE FORM
NEW PATIENT INTAKE FORM Personal Information 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
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:
SHEILA WOLFSON, M.Ed., C.N.S. Nutritionist and Health Counselor. 20 Main Street, Suite 300, Natick, MA Phone/Fax (508)
SHEILA WOLFSON, M.Ed., C.N.S. Nutritionist and Health Counselor 20 Main Street, Suite 300, Natick, MA 01760 Phone/Fax (508) 875-3735 HEALTH HISTORY Name Date Address Phone (H) Phone(W) Weight Height Age
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
06/09/2005 Medical history and intake form
Medical history and intake form Please complete this form as accurately as possible - it helps to provide you with the best possible treatment. Address including postcode Contact numbers Home/work/mobile
Patient Health History
Patient Health History Name: (first) (middle) (last) Date: / / Date of Birth: / / Age: Gender: M/F Marital status: S M D W Phone: Email: Children (quantity/age): Mailing Address: 1. Please identify the
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
Carlette Zottola Lac, MSTOM Acupuncture New Patient Intake Form. Patient Information. Emergency Contact Information.
Carlette Zottola Lac, MSTOM Acupuncture New Patient Intake Form Patient Information Name: Date of Birth: Age: Gender(please circle) M or F Occupation: Address: City, State, Zip: Email: Home Phone: Cell
ACUPUNCTURE FOR HEALTH WENDY STALKER R.Ac. Dip.Ac. B.Sc. Name: Date of Birth: Date:
Name: Date of Birth: Date: Address: Postal Code: Occupation: Telephone: Day: Cell Phone: E-mail address: Emergency Contact: Evening: Telephone: Male Female Where did you hear about Acupuncture for Health?
OKANAGAN HEALTH & PERFORMANCE Inc.
OKANAGAN HEALTH & PERFORMANCE Inc. Chiropractic, Massage Therapy, Kinesiology, Physiotherapy, Acupuncture, Naturopathic Medicine & Osteopathy 104-1100 Lawrence Ave, Kelowna, BC, V1Y 6M4 (250) 860-6295
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,
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(
Methotrexate. Information for patients. Paediatric Rheumatology. Feedback
Feedback We appreciate and encourage feedback. If you need advice or are concerned about any aspect of care or treatment please speak to a member of staff or contact the Patient Advice and Liaison Service
NEW PATIENT FORM. Please print in ink and fill in all blanks Please fill out front and back. Patient s Full Name
NEW PATIENT FORM Please print in ink and fill in all blanks Please fill out front and back Patient s Full Name Date of Birth Age Sex Social Security Number Referring Doctor or Family Physician Phone #
Family Self-Care and Over the Counter Medications Program. Sponsored by: FAHC Department of Pharmacy
Family Self-Care and Over the Counter Medications Program Sponsored by: FAHC Department of Pharmacy What are Over the Counter Medications? Nonprescription medications and products Often referred to as
ALLERGY & ASTHMA SPECIALISTS, P.C.
ALLERGY & ASTHMA SPECIALISTS, P.C. Leonard Silverstein, M.D. Ruth L.K. Gold, M.D. Health Questionnaire Jennifer A. Sherman, D.O. Niya Wanich, M.D Patient: D.O.B.: / / Age: Date: / / Height: Weight: Reason
1. Have you ever had or now have: 2. Have you ever had or now have:
1. Have you ever had or now have: 2. Have you ever had or now have: Yes No Please Check each item no blanks CARDIOVASCULAR Yes No Often Seldom 1. Chronic or frequent colds 1. Shortness of breath with normal
CASE HISTORY. Address: City: State: Zip: Date of Birth: Age: address: Occupation: Employer: Spouse's Employer: Referred by:
CASE HISTORY Account #: Please complete this form using your keyboard, then print it using the print function of your browser. You can then sign the form and bring it with you to your first appointment.
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:
Proposed changes to prescribing in Croydon. Lambeth. NHS prescriptions in Lambeth
Proposed changes to prescribing in Croydon Lambeth NHS prescriptions in Lambeth 1 NHS Lambeth Clinical Commissioning Group 1. Introduction We are seeking your views on our proposals to make some changes
Weekly standard dose. Paclitaxel (Taxol) and carboplatin
paclitaxel (taxol) and carboplatin Paclitaxel (Taxol) and carboplatin This leaflet is offered as a guide to you and your family. The possible benefits of treatment vary; for some people chemotherapy may
Northeast Ohio Urogynecology Patient History Intake Form. Last Name First Name Age. Date of Birth Race Referring Physician.
Northeast Ohio Urogynecology Patient History Intake Form Last Name _First Name Age_ Date of Birth Race Referring Physician Reason for Visit: _ Allergies: Preferred Lab (circle): QUEST LABCARE PLUS LABCORP
For the Patient: LUSCPE
ABOUT THIS MEDICATION For the Patient: LUSCPE Other Names: Treatment of Extensive Stage Small Cell Lung Cancer (SCLC) with Cisplatin and Etoposide LU = LUng SC = Small Cell PE = CisPlatin, Etoposide What
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
History of Present Illness Please answer the following questions
Last Name First Name Date of Birth: / / What is the main reason for your visit today? Social Security Number: History of Present Illness Please answer the following questions Bladder Cancer Urinary Tract
Simplotan* tablets Tinidazole (tin-id-azole)
Simplotan* tablets Tinidazole (tin-id-azole) Consumer Medicine Information What is in this leaflet This leaflet answers some common questions about Simplotan. It does not contain all the available information.
Please answer the questions on this form as they relate to the person being evaluated.
Please answer the questions on this form as they relate to the person being evaluated. Although your history and symptoms are very important in our analysis of your condition, it is also important for
For the Patient: Trastuzumab emtansine Other names: KADCYLA
For the Patient: Trastuzumab emtansine Other names: KADCYLA Trastuzumab emtansine (tras tooz' ue mab em tan' seen) is a drug that is used to treat some types of cancer. Trastuzumab emtansine is a clear
2. Approx. Date of Onset: 3. Approx. Date of Onset:
Healthy Balance Lisa A. Dulac, L.Ac. Acupuncture Patient Intake Form Present Health Concerns: Please list your most important health concerns in order of their significance. 1. Approx. Date of Onset: 2.
PACKAGE LEAFLET: INFORMATION FOR THE USER. GRAZAX 75,000 SQ-T oral lyophilisate
PACKAGE LEAFLET: INFORMATION FOR THE USER GRAZAX 75,000 SQ-T oral lyophilisate Standardised allergen extract of grass pollen from Timothy (Phleum pratense) Read all of this leaflet carefully before you
Everolimus (Afinitor )
Everolimus (Afinitor ) ( e-ver-oh-li-mus ) How drug is given: By mouth Purpose: to slow the growth of cancer cells in kidney cancer and other cancers How to take the drug Take with or without food and
Sorafenib (so-ra-fe-nib) is a drug that is used to treat many types of cancer. It is a tablet that you take by mouth.
For the Patient: Other names: Sorafenib NEXAVAR Sorafenib (so-ra-fe-nib) is a drug that is used to treat many types of cancer. It is a tablet that you take by mouth. A blood test may be taken before each