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Microsoft word - 4 injection history sheet 09-15-2011.doc

INJECTION HISTORY SHEET
‰ Brick ‰ CMCH ‰ EHT ‰Festival ‰Galloway ‰ Somers Point ‰ Wall Twp.
Name________________________________________ Date___________________ Age_________
LMP________Weight ________ Exam______________Referring Physician____________________
Why are you having today’s exam?______________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
Have you had any recent prior CT, MRI, Ultrasound CT/PET, NM or endoscopy exams? ‰Yes ‰No
If so, where and when:________________________________________________________________
Prior surgical and medical history:_______________________________________________________
___________________________________________________________________________________________________________________________
List all medications:__________________________________________________________________
Level of Pain (1 – 10):_________
Have you ever had x-ray dye? ‰Yes ‰No _______________ Reaction? ‰Yes ‰No _______________
Are you pre-medicated with Prednisone/ Benadryl for today’s exam? ‰Yes ‰No
IMPORTANT: If you are allergic to iodine (x-ray dye), please notify the technologist.
Smoking History
‰No ‰Yes __________________________________________________________________ Describe __________________________________________________ Do you take the following: Glucophage Metformin Riomet
Glucophage XL Glucovance
Metaglip Fortamet
Janumet Avandamet
Actoplus-met Glumetza
Multiple Myeloma ‰No ‰Yes The above medications must be stopped
Sickle Cell Anemia ‰No ‰Yes for 48 hours AFTER this exam.
Breast Feeding ‰No ‰Yes
Cancer ‰No ‰Yes
Chemotherapy ‰No ‰Yes Finished? ‰No ‰Yes When____________ Where____________
Radiation ‰No ‰Yes Have you had treatment since your last CT Scan? ‰No ‰Yes
Myasthenia Gravis ‰No ‰Yes If yes, what type of treatment______________________________
Patient/Parent/Guardian Signature_______________________________________________________
- - - - - - - - - - - - - - - -- - - - - - - - - - - - - - - - - Technologist Notes - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
NON CONTRAST REASON_________________________________________________________________
Most Recent Labs: BUN ___________ Creatinine _______ as of ______________ ‰None available
CURRENT INJECTION: _______ cc OPTIRAY 300/320 OMNIPAQUE 180/300
ISOVUE 370 VISIPAQUE 320
Lot # _______________ Expiration Date_______________
Injected by:____________________________________ Site:______________ Angiocath :______g
Reaction: ‰No ‰Yes Description _____________________________________________________
Dr. ________________________________________ was on the premises at the time of injection.
(09/2011) # 4 Injection History Sheet.doc

Source: http://www.atlanticmedicalimaging.com/sites/atlanticmedicalimaging.com/files/pdf/Injection_History_Sheet.pdf

Microsoft word - wma82932.doc

EUSPC-ACX-T-092008 (EUSPC 072008 +approved Referral text following EC Decision (Sept 2008) SUMMARY OF PRODUCT CHARACTERISTICS 1. NAME OF THE MEDICINAL PRODUCT <ARCOXIA (see Annex 1)> 30 mg film-coated tablets <ARCOXIA (see Annex 1)> 60 mg film-coated tablets <ARCOXIA (see Annex 1)> 90 mg film-coated tablets <ARCOXIA (see Annex 1)> 120 mg film-coated tablets [See

Pediatric intake questionnaire2.xlsx

Keweenaw Holistic Family Medicine Pediatric Intake FormParents marital status (circle): Married / Separated / Living Together / Other:Current Grade in School:Please indicate the severity of your symptoms by checking the box that applies to each symptom (sx). Part I: ENT - Allergy Symptoms Mild Moderate Severe Moderate Severe Moderate No Sx Mild Sx No Sx Mild Sx Severe Sx

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