|
|
|
- Dwain Lawson
- 6 years ago
- Views:
Transcription
1
2
3
4
5
6
7
8
9
10 Scientific Principles of Medicine Gross Anatomy Neuroanatomy Behavior Nutrition Physiology Hiso/Cell Genetics Immunology Pathology Neuroscience Microbiology Biochemistry Pharmacology Embryology Clinical medicine
11 Scientific Principles of Medicine Course Goals
12 Traditional curriculum Silo approach Clinical presentation based curriculum Integrated approach Multiple departments One department (Medical Education) Faculty not really focused on teaching (e.g. clinical assignments) Courses of specific duration Faculty are focused on teaching Scientific principles of medicine (SPM) course last 2 years Courses in defined finite order System based Clinical presentation based Little communication between departments Communication of the faculty of multiple disciplines
13
14 INTRODUCTION TO HEALTH AND DISEASE MUSCULO SKELETAL SYSTEM GI SYSTEM LIVER AND HEMATOLOGY CARDIO VASCULAR AND PULMONARY RENAL SYSTEM
15 NEURO SCIENCE ENDOCRINE REPRODUCTION MIND AND HUMAN DEVELOPMENT INTEGRATION OF SYSTEMS & USMLE PREPARATION
16 Duration: 10 weeks Clinical Presentations: PHE - Adult PHE - Child Sore Throat Fever Wound
17 Clinical Presentations: Bone Fractures & Dislocations Joint Pain Musculoskeletal Lumps & Masses Limp & Deformity Numbness & Pain Weakness & Loss of Motion Skin Lesions: Rash Eczema and Pruritus Hair and Nail Disorders
18 Clinical Presentations: Dysphagia Nausea & Vomiting Diarrhea Constipation Abdominal Pain GI Bleeding
19 Clinical Presentations: Abnormal Liver Function Tests Jaundice Abdominal Distension Abnormal Hemoglobin Abnormal WBCs Lymphadenopathy Coagulation Abnormalities
20 Clinical Presentations: Chest Discomfort Mediastinal Mass Abnormal Heart Sounds Cardiac Murmurs Syncope Palpitations Pulse Abnormalities Hypertension & Shock Dyspnea Cough Wheezing Cyanosis Hemoptysis
21 Clinical Presentations: Edema/Anasarca/Ascites Disorders of serum sodium Disorders of serum potassium Abnormal Hydrogen ion concentration Calcium/Phosphate/Magnesium metabolism Urinary frequency Blood pressure/hypertertension Renal failure
22 Clinical Presentations: Visual disturbances Diplopia / Strabismus Eye redness Conjuctivitis / Keratitis Hearing loss / Tinnitus Vertigo and Dizziness Movement disorders Headache Seizures Weakness and Paralysis Stroke Mental status / Altered mental status
23 Clinical Presentations:
24 Clinical Presentations:
25 Clinical Presentations:
26 A Typical Calendar Week Mon Tue Wed Thu Fri Clinical presentation SPM SPM SPM SPM SPM SPM SPM SPM SPM WCE MC SPM SPM SPM SPM SPM SPM FA3 MSC1 MC WCE LUNCH MSC2 FA1 Self-Study Self-Study (Clinic 1x per month) Self-Study (Clinic 1x per month) FA2 MSC3 Self-Study SPM = Scientific Principles of Medicine WCE = Case Studies - small group session FA = SPM Formative Assessment MSC = Medical Skills Course MC = Master s Colloquium (Medical Ethics and Professionalism)
27 Educational Methods & Learning Experiences
28
29
30 75% Grading is Pass/Fail Passing grade = 75% Rule 1: If all student grades > 75%, all pass.
31
32
33
34
35
36 Traditional curriculum Silo approach Clinical presentation based curriculum Integrated approach Multiple departments One department (Medical Education) Faculty not really focused on teaching (e.g. research projects) Courses of specific duration Faculty are focused on teaching Scientific principles of medicine (SPM) course last 2 years Courses in defined finite order System based Clinical presentation based Little communication between departments Communication of the faculty of multiple disciplines
37
38
39
40
41 Clinical Presentation Based Curriculum Provides a roadmap to organize student s / physician s thinking
42
43
44 INTRODUCTION TO HEALTH AND DISEASE MUSCULO SKELETAL SYSTEM GI SYSTEM LIVER AND HEMATOLOGY CARDIO VASCULAR AND PULMONARY
45 NEURO SCIENCE RENAL SYSTEM ENDOCRINE REPRODUCTION MIND AND HUMAN DEVELOPMENT
46 YEAR 3 Internal Medicine Family Medicine I N OBGYN Pediatrics I N Surgery Psychiatry I N T T T E E E R R R S S S E E E S S S S S S I I I O O O N N N LONGITUDINAL LONGITUDINAL LONGITUDINAL (IM/ FM) (MATERNAL/FETAL) (SURGERY/PSYCHIATRY)
47 Critical Care Emergency Medicine Neurology Electives Capstone
48
49
50 Preclinical years Clinical years Scheme presentations Worked case examples Medical skills Imaging sessions Anatomy and embryology Physiology Biochemistry Cell biology & Histology Microbiology Immunology Pharmacology Genetics Pathology Behavioral sciences Nutrition
51 Scientific Principles of Medicine Gross Anatomy Neuroanatomy Behavior Nutrition Physiology Hiso/Cell Genetics Immunology Pathology Neuroscience Microbiology Biochemistry Pharmacology Embryology Clinical medicine
52
53
54 THREADS Geriatrics Special needs population Patient care Basic sciences Scholarly activity
55
56
57
58 Educational Methods & Learning Experiences
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73 Radiology Faculty Arvin E. Robinson, MD, MPH Branko Plavsic MD, PhD Jesus Calleros, MD Melhem Ghaleb, MD Jose Gavito, MD Luis Ramos, MD Adolfo Escobar, MD Sanja Kupesic Plavsic, MD, PhD Jose Ulloa, MD Hugo Isuani, MD Jorge Sarmiento, MD Naomi Bruner, MD
74 Unit Description Area Editors II Musculoskeletal Hugo Isuani Jorge Sarmiento Neurology Jose Gavito Luis Ramos Jorge Sarmiento III Gastrointerstinal Jesus Calleros, Adolfo Escobar Branko Plavsic Arvin Robinson Jorge Sarmiento Hematology Jesus Calleros, Adolfo Escobar Branko Plavsic Arvin Robinson Jorge Sarmiento IV Cardiovascular Jesus Calleros, Adolfo Escobar Melham Ghaleb Branko Plavsic Arvin Robinson Pulmonary Jesus Calleros, Adolfo Escobar Branko Plavsic Arvin Robinson
75 Unit Description Area Editors VI Renal/Endocrine Jesus Calleros, Adolfo Escobar Branko Plavsic Arvin Robinson Jorge Sarmiento VII Obstetrics and gynecology Sanja Kupesic Jose Ulloa Melham Ghaleb Jorge Sarmiento VIII Mind and Human Development Jose Gavito Luis Ramos Jorge Sarmiento Pediatrics Arvin Robinson Jorge Sarmiento IX Derm and special senses Jose Gavito Luis Ramos
76
77
78
79 Basic Science Clinical Knowledge Medical Skills SCI (Preclinical years) Clerkship Efficiency evaluation & Advances / New topics Scholarly projects & Research Feedback & Modifications
80 It works It doesn t It works It doesn t May be we do need a better way to measure results and evaluate the effectiveness
81
82
Course Outline: Blood and Immunology. DRAFT 14 May 2013
Course Outline: Blood and Immunology DRAFT 14 May 2013 What we need to decide What do medical students need to learn about Hematology and Immunology? What knowledge/skills does an undifferentiated physician
TEXAS VASCULAR ASSOCIATES, P.A. PATIENT CLINICAL INTAKE FORM
TEXAS VASCULAR ASSOCIATES, P.A. PATIENT CLINICAL INTAKE FORM PATIENT NAME: DATE OF BIRTH: TVA Physician being seen: Date of Visit: PAST MEDICAL HISTORY HEART PROBLEMS NEUROLOGICAL Congestive Heart Failure
T- Timing- concise vs. complete and thorough, depending on need of presenter and audience. E- Elicit- ask for feedback- more information needed? Less?
Review of STAGE presentation framework (from umass.macy.edu, revised Alicia Monroe, MD from 2005 STFM) S- style organization, sequencing adequate to build a case for your diagnosis or a story T- Timing-
Western States Chiropractic College
Western States Chiropractic College Chiropractic Program Chiropractic students undergo a rigorous course of study similar to that of other health care professionals. Entrance requirements are also similar.
NEUROLOGICAL SURGERY, P.C.
NEUROLOGICAL SURGERY, P.C. PATIENT INFORMATION Name Date of Birth Age Address City Sate NY Zip Home ( ) - Cell ( ) - Work ( ) - Ext: Email Address _ Sex M F Soc. Sec. #: / / Single Married Widowed Separated
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
Amarillo Surgical Group Doctor: Date:
Office Visit Information (General Surgery) Amarillo Surgical Group Doctor: Date: Patient s Information Name: Last First Middle Social Security #: Date of Birth: Age Gender: [ Male / Female ] Marital Status:
DNA CENTER New Patient Information
DNA CENTER New Patient Information Name Email: Address City State Zip Home Phone Work Cell Phone Social Security Number Date of birth Gender ( Male/Female) Age Please Circle: Hispanic/Latin or Non Hispanic/Latin
Contributors. Thanks to Peter Miller, MD; LCDR Kevin Preston, MD; and Keith Newbrough, MD for their generous contribution of images:
Contributors Thanks to Peter Miller, MD; LCDR Kevin Preston, MD; and Keith Newbrough, MD for their generous contribution of images: Peter Miller, MD, Indiana University School of Medicine Chapter 1: Figure
MARYWOOD UNIVERSITY PHYSICIAN ASSISTANT PROGRAM HISTORY, PHYSICAL, ASSESSMENT AND PLAN
MARYWOOD UNIVERSITY PHYSICIAN ASSISTANT PROGRAM HISTORY, PHYSICAL, ASSESSMENT AND PLAN PA: PRECEPTOR: MARYWOOD STAFF: PATIENT ID: AGE: SEX: DATE: Chief Complaint: History of Present Illness: 1 Medications:
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:
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
Patient Interview Form
Page 1 of 5 Patient Interview Form Patient Information First Name: MRN: Last Name: Date Of Birth: Contact Preference Email Telephone call- Work Telephone call - Home Email Please check one as your preferred
PATIENT INFORMATION SHEET
ALAMO NEUROSURGICAL INSTITUTE 414 W SUNSET, SUITE 205 SAN ANTONIO, TEXAS 78209 WWW.ANI-ONLINE.COM OFF: 210.564.8300 FAX: 210.564.8399 PATIENT INFORMATION SHEET Patient Name (Last, First, Mi): SSN: Street
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
SECTION OF NEUROSURGERY PATIENT INFORMATION SHEET
SECTION OF NEUROSURGERY PATIENT INFORMATION SHEET EC#: (for office use only) Patient s Name: Today s Date: Age: Date of Birth: Height: Weight: Physician you are seeing today: Marital Status: Married Work
Please list all medications you are currently taking (include aspirin, vitamins, hormones), Dosage, and Frequency.
GENERAL SURGICAL ASSOCIATES A practice of Lehigh Valley Physician Group Suite 208 ~ 1240 S. Cedar Crest Boulevard ~ Allentown, PA 18103 Phone: (610) 402-9780 PLEASE COMPLETE THIS FORM PRIOR TO YOUR VISIST
*Monitor for significant side effects, especially symptoms of neurological or cardiovascular events.
Assessment Prior to administration: Obtain complete health history including allergies, drug history, and possible drug reactions Assess reason for drug administration such as presence/history of anemia
Please list any treatments you have previously had for current illness. (Physical Therapy, Surgery, Radiation, etc.)
Date: Patient Name: D.O.B Last First M.I History of Present Illness: What is the reason for your visit? Date symptom started? Please list any treatments you have previously had for current illness. (Physical
sharp CP with deep breath or cough texture Cardiac chest pain (CP) Heme large or rapid, strong or
Review of Systems (ROS) Checklist Layman's Terms MBLD Session 1 General fever Mouth change in taste chills in mouth or tongue sweats bleeding gums night sweats lesions in mouth or gums weight change lesions
Coastal Digestive Diseases, P.C. MA New Pt Ht
Coastal Digestive Diseases, P.C. MA New Pt Ht Interview Form Limited Use Only Estab Pt Wt Name Nickname DOB Address Occupation Social Security # Married Single Email Address: Divorced Widowed Check Contact
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 #
PATIENT HEALTH QUESTIONNAIRE Radiation Oncology
REVIEWED DATE / INITIALS Safety: Yes No Are you at risk for falls? Do you have a Pacemaker? Females; Is there a possibility you may be pregnant? Allergies: Yes No If YES, please list medication allergies:
+ Color Change - + Hearing Loss - + Apnea - + Enuresis (urine - + Tremors - + Rash -
Review of Systems: 0-1 year old Constitution neg Eyes neg GI neg Neurological neg + Activity Change - + Eye Discharge - + Reflux - + Facial Asymmetry - + Appetite Change - + Eye Redness - + Vomiting -
FRIEDMAN & GREENHUT, DPM, PA PATIENT REGISTRATION FORM DOB. City, State, Zip
FRIEDMAN & GREENHUT, DPM, PA PATIENT REGISTRATION FORM Patient Information Social Security # Date DOB First Name MI Last Address City, State, Zip Home # Cell # Male Female Email Single Married Widowed
Ebele C. Chira, MD 1055 Clarksville Street, Suite 190, Paris, TX Phone (903) Fax (903)
Ebele C. Chira, MD 1055 Clarksville Street, Suite 190, Paris, TX 75460 Phone (903) 905-4609 Fax (903) 905-4611 Enclosed are forms for you to complete prior to your appointment. Please bring these completed
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
Interventional Pain Medicine. P. Tennent Slack, M.D. Dr. Greg Jackson, M.D. Ben Fleming, PA-C
Interventional Pain Medicine P. Tennent Slack, M.D. Dr. Greg Jackson, M.D. Ben Fleming, PA-C Gainesville Braselton Medical Park 1, Suite 300 Medical Plaza B, Suite 402 1315 Jesse Jewell Parkway 1404 River
PATIENT HEALTH QUESTIONNAIRE Radiation Oncology
REVIEWED DATE / INITIALS Safety: Are you at risk for falls? Do you have a Pacemaker? Females; Is there a possibility you may be pregnant? Allergies: If YES, please list medication allergies: Do you have
Sick Call Screener Course
Sick Call Screener Course SOAP Note (1.3) 1.3-2-1 Enabling Objective 1.5 Document a patient encounter 1.3-2-2 SOAP Note Standard for documentation Designed to allow easy reference for follow-up care. (U.S.
West Campus Curricular Schedule
. ṢṬỤ. ḌẸṆ. Ṭ. ẠḌ. ṂỊṆỊṢṬṚ. ẠṬ. IṾẸ. Ṣ. ẸṚ. ṾỊC.ẸṢ... West Campus Curricular Schedule This schedule gives a general idea of a class day by Quarter at the West Campus. *Actual class times change each term
Cardiovascular Genetics Clinic Arrhythmia Questionnaire
Name: Address: Home Phone: Cell Phone: Email Address: Date of Birth: Primary Care Physician: Why have you been referred for a Cardiovascular Genetics Appointment? Have you had a genetics evaluation? If
Curriculum Overview for 1 st year students of English Division of the Medical Faculty Medical University of Gdańsk Academic Year 2016/2017
Curriculum Overview for 1 st year students of English Division of the Medical Faculty Gross Anatomy with Neuroscience 18 208 58-150 Exam Histology with Cell Physiology 9 102 24-78 Exam Biophysics 5 60
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
Patient Name Date of Birth MALE / FEMALE Date. Left handed or Right handed. Marital Status: Single Married Divorced Widowed Children?
PH NEW PATIENT HISTORY Patient Name Date of Birth MALE / FEMALE Date Occupation: Left handed or Right handed Marital Status: Single Married Divorced Widowed Children? Y or N # Previous Treating Physician:
Cardiovascular Genetics Clinic Vascular Questionnaire
Name: Address: Home Phone: Cell Phone: Email Address: Date of Birth: Primary Care Physician: Why have you been referred for a Cardiovascular Genetics Appointment? Have you had a genetics evaluation? If
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
PERSONAL MEDICAL AND FAMILY HISTORY Please check applicable boxes.
Name: DOB: PERSONAL MEDICAL AND FAMILY HISTORY Please check applicable boxes. TOBACCO USE: Quit Date Cigarettes Packs/Day Number of years smoked Pipe/Cigar Smokeless Tobacco Electronic or E-cigarette Secondhand
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:
PLAS/RECON SURGERY PATIENT HEALTH HISTORY
PLAS/RECON SURGERY PATIENT HEALTH HISTORY Chief Complaint - Please describe the problem that brings you into the office today: Allergies 1. Do you have any allergies? if so, please list To Medications?
Emory Clinic Department of Neurological Surgery Second Opinion Questionnaire
Emory Clinic Department of Neurological Surgery Second Opinion Questionnaire First Name: M.I. Last Name: Date of Birth: Phone: Marital Status: Married Divorced Separated Widowed Single Work Status: Employed
Patient Information Last Name: First Name: Middle Initial: Address: City: State: Zip Code:
Patient Information Last Name: First Name: Middle Initial: Address: City: State: Zip Code: Date of Birth (MM/DD/YY): Social Security #: Sex: Male Female Home Phone #: Mobile Phone #: Email Address: Marital
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
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:
1 Anatomy Atlas of Clinical Gross Anatomy 2 Anatomy Atlas of Human Anatomy 3 Anatomy Crash Course Anatomy 4E 4 Anatomy Fitzgerald's Clinical
Specialty Title 1 Anatomy Atlas of Clinical Gross Anatomy 2 Anatomy Atlas of Human Anatomy 3 Anatomy Crash Course Anatomy 4E 4 Anatomy Fitzgerald's Clinical Neuroanatomy and Neuroscience 5 Anatomy Gray's
MCKAY UROLOGY LINCOLNTON OFFICE PATIENT HISTORY FORM
Patient name: MRN #: Current Medications (prescription and over the counter medications including vitamins, herbs, aspirin, antacids, injectables, hormones and birth control medication) If you brought
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
SCHOOL OF HEALTH SCIENCES Degree: DOCTORATE Credits: 278 Program: NATUROPATHIC MEDICINE CURRICULUM BOTANICAL MEDICINE COURSES
SCHOOL OF HEALTH SCIENCES Degree: DOCTORATE Credits: 278 Program: NATUROPATHIC MEDICINE CURRICULUM Description: Naturopathic Medicine is a comprehensive system of health care within the complementary and
New Patient Questionnaire Pediatric Orthopaedic Surgery
Page 1 of 5 New Patient Questionnaire Pediatric Orthopaedic Surgery First Name: Last Name: Middle: DOB: Height: Weight: Primary Care Physician/Pediatrician Name: Address: Phone Number: Chief Compliant
5210 E Farness Drive P: (520) Tucson, AZ F: (520) E:
Personalized HealthC are Patient Registration 5210 E Farness Drive P: (520) 795-4100 Tucson, AZ 85712 F: (520) 795-4224 E: www.phcoftucson.com First Name Middle Last Name DOB Age Sex SSN Race Ethnicity
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
Electives Diversification Policy
Electives Policy Rationale The Association of Faculties of Medicine of Canada Undergraduate Deans acknowledge the role that electives play as part of the curriculum of every medical program in Canada.
Patient History (Please Print)
Patient History (Please Print) Date: Name: Email: Phone: (Home) (Mobile) (Work) Address: City: Zip: Birth Date: / / Male Female Spouse/Parent Name: # of Children: Married Single Divorced Widowed Are you
Patient Intake Form. Name: Date of Birth: Social Security No.: Address: City: State: Zip:
Patient Intake Form Name: Date of Birth: Social Security No.: Address: City: State: Zip: Phone (circle 1) home / cell / work: Marital Status: Single / Married / Divorced / Widowed Work Status: Employed
Please describe, in detail, when the symptoms began:
161 East Mallard Drive, Suite 130, Boise, ID 83706 (208) 947-0100 New Patient Intake Patient Name: Primary Care Physician: Date: Email address: How did you hear about AVT (mark all that apply) Online On
Broward Oncology Associates, P.A. PATIENT INFORMATION
NAME: BIRTHDATE: AGE: LOCAL ADDRESS (Street city state zip): HOME TELEPHONE# CELL # SOCIAL SECURITY #: - - SEX MARITAL STATUS WHAT IS YOUR HT? WHAT IS YOUR WT? EMPLOYER WORK# SPOUSE'S NAME SPOUSE'S EMPLOYER
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
New Patient History. Name: DOB: Sex: Date: If yes, give the name of the physician who did your evaluation or ordered your tests:
New Patient History Name: DOB: Sex: Date: Chief Complaint: 1. Give a brief description of the problem you are seeking treatment for today: 2. Have you been evaluated for this problem or had any tests for
Please answer all questions in blue or black ink by filling in the blank or circling. SOCIAL HISTORY
PATIENT QUESTIONNAIRE / ASSESSMENT Endocrinology Form Please answer all questions in blue or black ink by filling in the blank or circling. SOCIAL HISTORY Date Phone (H) (W) (C) Age Male Female Marital
MEDICAL QUESTIONNAIRE (male)
MEDICAL QUESTIONNAIRE (male) Slievemore Clinic, Old Dublin Road, Stillorgan, Co. Dublin. Tel 01-2000501/502 Fax: 01 2780248 The appointment comprises of a discussion about this questionnaire and a subsequent
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:
VASCULAR SURGERY PATIENT HEALTH HISTORY
VASCULAR SURGERY PATIENT HEALTH HISTORY Chief Complaint - Please describe the problem that brings you into the office today: Allergies 1. Do you have any allergies? if so, please list To Medications? To
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
Vanessa Schulte, CCMA Practice Administrator Huntsville Hospital Pediatric Neurology
Kimberly L. Limbo, MD Kellie D. Anderson, CRNP Dear Parent, Thank you for choosing Huntsville Hospital Pediatric Neurology for your child s medical care. Our website should help answer any questions about
Arcana Center for Integrative Medicine
Arcana Center for Integrative Medicine Patient s Name: Date of Birth: Reason for today s visit: Past Medical History Primary care physician: Date of last exam: (sick or well) Physician s Address: Office
HEMATOLOGY/ONCOLOGY PATIENT INITIAL HISTORY. Name Age Date. Physician to who report is to be sent
HEMATOLOGY/ONCOLOGY PATIENT INITIAL HISTORY Name Age Date Physician to who report is to be sent Why have you come to see the doctor? Patient Surgical History: Please list all operations, and the dates
Weill Cornell Vascular
Weill Cornell Vascular Name: City: State: Zip Code: DOB: Age: Phone: (H) (W) (C) Indicate Primary: Email address: Religion: Ethnic Group: Race: Have you traveled to Africa (specifically (Guinea, Liberia,
725 Jesse Jewell Pkwy, Suite 390 Gainesville, GA (770) (770) (facsimile)
Charles Nash, III, M.D., F.A.C.P. Richard J. LoCicero, M.D. Anup K. Lahiry, M.D. Timothy M. Carey, M.D. Andrew Johnson, M.D. 725 Jesse Jewell Pkwy, Suite 390 Gainesville, GA 30501 (770) 297-5700 (770)
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
Competencies and Objectives
Competencies and Objectives Chapter 1 EMS Systems Preparatory Emergency Medical Services (EMS) Systems Research Public Health Chapter 2 Workforce Safety and Wellness Medicine Infectious Diseases Preparatory
2. Have your symptoms affected your ability to carry out your daily activities? YES NO
QUESTIONNAIRE Page 1 of 5 Date: Referring MD (Name, Address, Phone Number): Primary Care Physician (Name and Address, Phone Number): Reason for visit: 1. How long have you had symptoms? Describe your symptoms?
NORTHERN VIRGINIA PULMONARY AND CRITICAL CARE ASSOCIATES, P.C.
NORTHERN VIRGINIA PULMONARY AND CRITICAL CARE ASSOCIATES, P.C. Past Medical History AIDS/HIV disease Anemia Asthma Bronchitis Cancer Date of last Chest X-ray Diabetes Mellitus, Type I Diabetes Mellitus,
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
Osher Center for Integrative Medicine Pediatric Intake Form Name: Date: Date of Birth: Age: Current Pediatrician:
Pediatric Intake Form Name: Date: Date of Birth: Age: Current Pediatrician: How did you hear about us? What are your goals for this visit? Where would you like to see improvement in your child s health?
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
ANY FAMILY HISTORY OF ANEURYSM OR DVT?
NAME: D/O/B: DATE: MR# WHAT PROBLEM(S) BRINGS YOU HERE TODAY? WHO SENT YOU TO US? DOCTOR/OTHER WHICH DOCTOR? WHAT SURGERY HAVE YOU HAD AND WHEN? (LIST) 1. 2. 3. 4. 5. 6. 7. HOW MUCH ALCOHOL DO YOU DRINK
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
MEDICAL ASSESSMENT PART 1 - SOCIAL HISTORY
Smoking history Alcohol history Never Quit Never Quit PART 2 - MEDICAL HISTORY Date of last colonoscopy? Date of last mammogram? Date of last pap smear? Date of last flu vaccine? Date of last pneumonia
New Patient Specialty Intake Form Department of Surgery
This form contains questions specific to the Department of Surgery. If you are new to Baylor College of Medicine and have not been seen in any of our offices, please be sure to complete our New Patient
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
- YOUR HEALTH HISTORY - (PLEASE COMPLETE ALL PAGES )
NAME (Please Print) First Name M.I. Last Name DATE of BIRTH / / - YOUR HEALTH HISTORY - (PLEASE COMPLETE ALL PAGES ) Exam Date:,20 PRESCRIPTIONS DRUGS Please Print MEDICATIONS NAMES ONLY NO PRESCRIPTION
Joseph S. Weiner, MD, PC Patient History Form
Date: / / NAME: Last First M. I. Age: Sex: q F q M Birthdate: / / What specific questions or goals do you have for this appointment? Please list the names of other clinicians you have seen for this problem:
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:
NEW PATIENT HEALTH HISTORY
NEW PATIENT HEALTH HISTORY Patient Name Today s Date Age Birth Date Date of last physical examination What is your reason for initial visit? Pharmacy Name & Telephone # NOTE: If you have prior records
Health Questionnaire
Patient Name Date of Birth Thank you for choosing Southern Cancer Center for your care. To help us best prepare for your appointment, please complete this form and bring it to your appointment. If you
Name: [Type text] Date of Birth: ENDOCRINOLOGY HEALTH HISTORY. What is the reason for your visit?
![Name: [Type text] Date of Birth: ENDOCRINOLOGY HEALTH HISTORY. What is the reason for your visit?](/thumbs/87/97078208.jpg "Name: [Type text] Date of Birth: ENDOCRINOLOGY HEALTH HISTORY. What is the reason for your visit?")
ENDOCRINOLOGY HEALTH HISTORY What is the reason for your visit? MEDICATIONS List current prescription and over-the-counter medications. Also list current vitamin, herbal, and nutritional supplements: MEDICATION/SUPPLEMENT
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
Rosen s Emergency Medicine 2018, 9/e Table of Contents
Rosen s Emergency Medicine 2018, 9/e Table of Contents Dr.hamidmirjalili@gmail.com Telegram: @medup PART I : Fundamental Clinical Concepts Section One : CRITICAL MANAGEMENT PRINCIPLES 1. Arway >> page
Review of Systems NAME: DATE OF BIRTH: DATE COMPLETED: Dear Patient,
LOS ANGELES CANCER NETWORK NEW PATIENT HEALTH QUESTIONNAIRE NAME: DATE OF BIRTH: DATE COMPLETED: Dear Patient, In order to offer optimal care for you, we need to understand your complete health status
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
Nursing Process Focus: Patients Receiving Dextran 40 (Gentran 40)
Assess for presence/history of hypovolemia, shock, venous thrombosis. Assess vital signs: Hypovolemic shock secondary to surgery, burns, hemorrhage, other serious condition PT and PTT abnormalities Venous
Name : Date of Birth : Social Security #: Age: Address: City: State: Zip Code: Home Phone: Work Phone: Cell Phone: Address: May we leave a
Name : Date of Birth : Social Security #: Age: Address: City: State: Zip Code: Home Phone: Work Phone: Cell Phone: Email Address: May we leave a message? Home Work Cell PLEASE DO NOT LEAVE A MESSAGE Marital
R. John Brewer EMT-P Dental Education Inc. PATIENT ASSESSMENT
R. John Brewer EMT-P Dental Education Inc. PATIENT ASSESSMENT Patient Assessment Patient assessment is made up of two parts - History - Physical Exam Patient assessment In medical cases obtaining an adequate
3855 Burton Street SE Suite A, Grand Rapids, MI Phone Fax Patient Information. Address: City: State: Zip:
3855 Burton Street SE Suite A, Grand Rapids, MI 49546 Phone 616.323.3102 Fax 616.323.3061 Patient Information Patient Name: Preferred Language: Address: City: State: Zip: Home Phone: Cell Phone: Cell Carrier:
EMS 202: Emergency Medical Technician Course Schedule
0- Aug EMS 0: Emergency Medical Technician Course Schedule (Section 111 - Tuesday/Thursday Mornings) ***UNLESS OTHERWISE STATED, ALL ASSIGNMENTS ARE DUE ON THE NEXT DAY OF CLASS*** **IT IS STRONGLY SUGGESTED
RECOMMENDED COURSE ORDER
Although you have the flexibility to view the videos in any order, we strongly recommend that you watch the videos in the order in which your dashboard presents them regardless of how many videos you view
Capital Health Medical Center - Hopewell NEUROSURGICAL-ONCOLOGY Patient History
Capital Health Medical Center - Hopewell NEUROSURGICAL-ONCOLOGY Patient History Please take a few minutes and complete the following questions before you see the doctors so that we may learn a bit more
Hospital he hospital is located near the interchange of highway 217 and (US 26).
Welcome to our Clinic! Our goal is to provide you with the highest quality medical care available. Please bring the completed enclosed paperwork along with your insurance card and legal picture ID to your
Patient to complete this information
Patient to complete this information Patient s Name Birth date Today s date Referring Physician Primary Care Physician Age Occupation Retired, how long? Prior operations Medications Type Date Name Dose
MEDICAL DATA SHEET For Patients 18 years of age and older
MEDICAL DATA SHEET For Patients 18 years of age and older NAME: DATE: / / AGE: DOB: / / 1. What is the main reason you are seeking a physician s advice? 2. Please list all allergies: Drug Allergies: Other