“Medical Wellness & Life Balance”
Client Name: _____________________________________________ Date: ____________
I am on the following medication: Birth Control_______________ Is there a Chance you are pregnant?
_____ If on CARBATROL, TRILEPTAL, or DEPAKOTE and female, what birth control method do you
use?_________________________________________________________________________________________________
Take HERBAL REMEDIES? Specify, ________________________________________________________________________
Vitamins? _______________________________________________________ ALLERGY SHOTS? ______________________
Do you have Mitral Valve Prolapse?_____________
LIST YOUR ALLERGIES: ___________________________________________________________
CURRENT MEDICATION you are taking (include meds you were taking on your last session here).
List each medication and daily dosage.
1. _______________________________! ________!
2. _______________________________ !__________
3. _______________________________! ________!
4. _______________________________! __________
5. _______________________________! ________!
6. _______________________________! __________
New Medication since your last session. Please include over the counter medication:
1. _______________________________! __________!
2. _______________________________! __________
3. _______________________________! __________4. _______________________________!
Other doctors, psychologists, coaches, or ministers you have seen since your last session:
______________________________________________________________________________________________________________
***Positive Changes in Your Life Since Last Session: ____________________________________________________
______________________________________________________________________________________________________________
***Challenges In Your Life Since Last Session: _________________________________________________________
______________________________________________________________________________________________________________
***Things I would like to discuss and or evaluate with the doctor, nurse, coach, or minister today:
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Return Date: _________________ Coach(es): _________________________________________ Date: _________________
Furosemide (10 mg/mL) Fliptop Vial AnsyrTM Plastic Syringe WARNING: Furosemide is a potent diuretic which, if given in excessive amounts, can lead to a profound diuresis with water and electrolyte depletion. Therefore, careful medical supervision is required and dose and dose schedule must be adjusted to the individual patient’s needs. (See DOSAGE AND ADMINISTRATION.) DES
CASAMENTO SURPRESA DO ANO Opiniões divergentes em torno do romance explosivo entreastros de Hindenburg : casamento dos atores Bruno di Blasee Greta Woolston provoca a mídia. Tudo começou no set de Hindenburg , megalançamentodo ano passado que bateu recordes e conquistou seteestatuetas do Oscar, incluindo a de melhor filme. Apesar doromance entre os personagens heroicos na telona, o p
“Medical Wellness & Life Balance”
Client Name: _____________________________________________ Date: ____________
I am on the following medication: Birth Control_______________ Is there a Chance you are pregnant?
_____ If on CARBATROL, TRILEPTAL, or DEPAKOTE and female, what birth control method do you
use?_________________________________________________________________________________________________
Take HERBAL REMEDIES? Specify, ________________________________________________________________________
Vitamins? _______________________________________________________ ALLERGY SHOTS? ______________________
Do you have Mitral Valve Prolapse?_____________
LIST YOUR ALLERGIES: ___________________________________________________________
CURRENT MEDICATION you are taking (include meds you were taking on your last session here).
List each medication and daily dosage.