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Microsoft word - 2010-07-new patient.doc

Patient Name: ________________________________________________________ NEW PATIENT MEDICAL HISTORY FORM -07/2010

Are you Right handed Left Handed both/ambidextrous

Your family doctor is ___________________their office is in the city and state of ______________

What caused your pain? CAR ACCIDENT WORKERS COMP OTHER _______________
Please draw on the figure where the pain is/where it travels/radiates to R L L R
(example, back going down right leg to the foot) The pain came on suddenly gradually when? ___________________ suddenly gradually when? ________________ If more than one location, what percentage of your pain is where? (example 90% back 10% legs) ________________________________ Describe your pain. Check all that apply and if there is a space provided, say where on your body: Electric shocks _________ Tingling _____________ Cramping Throbbing Sore Pins / needles __________ Numb ______________ Shooting ______________ OTHER (describe):_____________________________________ From 0 to 10, what does your pain range from during the day? (0 = no pain, 10 = unbearable)______ What makes it worse? (Check all that apply) OTHER (describe):______________________________________________________________ What makes it better? (Check all that apply) OTHER (describe): ______________________________________________________________ Is your pain ALL THE TIME HAS FLARE UPS BOTH: if flare ups, when? __________ G.M.O. This page has been reviewed ____________Date_________ Patient Name: ________________________________________________________ NEW PATIENT MEDICAL HISTORY FORM -07/2010
LIST ALL MEDICINES (psychiatric, diabetes, pain, etc.) YOU ARE TAKING OVER THE
COUNTER OR FROM OTHER (NOT-Greater Metropolitan Orthopaedics) DOCTORS:
No changes since last seen in a Greater Metropolitan Orthopaedics office so don’t need to write
See the list I brought with me
Anticoagulant/Anti-platelet Medicine
(Check all that apply):
Warfarin (Coumadin) Clopidogrel (Plavix)
Aggrenox / Any other blood thinners______ Medication Medication Medication Medication
Do you have any ALLERGIES to the following medications or items?
------------------------------------------------------------------------------------------------------------------------- Are you satisfied on your current pain meds? _________ Do you have enough medication? ______ What PAIN MEDICATIONS have you tried and STOPPED taking? Stopped because (side effect of, no relief, etc.) G.M.O. This page has been reviewed ____________Date_________ Patient Name: ________________________________________________________ NEW PATIENT MEDICAL HISTORY FORM -07/2010
Have you had any of the following within the last MONTH? (REVIEW OF SYSTEMS)
Fever (General) Balance problems (Neuro)
shortness of breath (Resp)
edema /Leg swelling (Cardiac) drowsiness
abdominal / stomach pain (GI)
Constipation with bowel movement muscle weakness WHERE?:___________________ Itchy skin (Skin)
lost weight without eating less
depressive symptoms/Feelings of sadness (Psych)
sleep disturbance/insomnia/ Difficulty sleeping libido decrease/low sex drive (GU) suicidal/ Thoughts of harming yourself
(MUSCULOSKELETAL)
R L Hand tingling that wakes you up at night R L Hand tingling that improves with shaking it SOCIAL HISTORY
OCCUPATION: __________ disabled homemaker office work retired unemployed NOT WORKING since ______________* STILL WORKING with…. *
Do you smoke? Yes No How many packs a day? ______________________ ALCOHOL don’t drink every day (minimal) 1-2 drinks a day (moderate) more than 3 drinks a day (heavy) less than a few times a year (seldom/rare) ANY previous illegal drug use: ____________________________________________________ G.M.O. This page has been reviewed ____________Date_________ Patient Name: ________________________________________________________ NEW PATIENT MEDICAL HISTORY FORM -07/2010
PRIOR PAIN
PAST SURGICAL HISTORY
PAST MEDICAL HISTORY
TREATMENTS/
What surgeries have you had?
What are your medical problems?
FAMILY HISTORY
What have you tried
No previous surgery
No significant medical disease
ORTHOPEDIC SURGERIES Alcoholism
PHYSICAL
ARTHROSCOPES…
MODALITIES:
INJECTION
JOINT REPLACEMENTS.
SPINE-please describe, like
FAMILY HISTORY
OTHER SURGERIES (yours)
Does your family have breast augmentation
Any of the problems
Listed below?
ANY OTHER SURGERIES?
Is there anything else we should know? ___________________________________________________ G.M.O. This page has been reviewed ____________Date_________

Source: http://greatermetroortho.com/docs/2010-07-Medical_History_Form_Hung.pdf

Microsoft word - prova.doc

ESTADO DE SANTA CATARINA PREFEITURA MUNICIPAL DE ORLEANS CONCURSUL ASSESSORIA E CONSULTORIA LTDA CONCURSO PÚBLICO Nº 02/2011. CADERNO DE PROVA ESCRITA CARGO: MÉDICO – OFTALMO Nº de Inscrição Nome do Candidato SETEMBRO DE 2011. INSTRUÇÕES * PREENCHA A TABELA ACIMA COM SEU NÚMERO DE INSCRIÇÃO E NOME COMPLETO * Duração da prova será de 03 horas, comp

Acknowledgment of risk-youth.doc

Acknowledgment of Risk - CONDITIONS for YOUTH - Warning – This is an important document which may affect your legal rights and obligations, please read it carefully. If you have any questions please call our office on 8165 2033. I, (Parent’s name) ___________________ acknowledge that Venture Corporate Recharge (Aust) Pty Ltd will provide my son/daughter (Child’s Na

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