Microsoft word - return h+p 100112.docx


Name____________________________________ DOB ________________ Age_____ Date_____________
Reason for this visit:_________________________________________________________________________

Please circle all changes that apply to your health in the last 6 months:
No changes
GENERAL: weight gain or loss (____ lbs), fever or chill, decrease in strength or exercise tolerance. ENT:
vertigo, bleeding gums. HEART: chest pain, palpitation, passing out. LUNGS: shortness of breath, wheezing,
coughing up blood. ABDOMEN: difficulty swallowing, blood in stool, dark stool, dark vomit. MUSCLE:
limited range of motion, numbness or tingling. NEURO: tremor, seizure, difficulty with speech. PSYCH:
hallucination, change in thought content, suicidal ideation. BREASTS: lump, swelling, nipple discharge.
URINARY: pain with urination, urgency, frequency, hesitancy, incontinence, blood in urine.
GYNECOLOGICAL: vaginal discharge, odor, itching, painful intercourse, bleeding after intercourse

If you still have your periods, complete this section:
First day of last menstrual period:________________________. Age period began:____ .
Periods are usually (please circle): regular/slightly irregular/very irregular. Bleeding is: heavy/moderate/light. They are:
very painful/slightly painful/not painful. Bleeding last: ____ days
If you are entering or have already entered menopause, complete this section:
Age of menopause: _____. Circle any of these following symptoms that you are experiencing: hot flashes, night sweat,
vaginal dryness, loss of interest in sex, insomnia, mood swings, forgetfulness, or urine leakage.
Date of last Pap smears: _________________________ Date of last Bone density test:_______________________
Date of last Mammogram:________________________ Date of last Colonoscopy: _______________________________
Please list all changes from your last visit (new medical problems/surgeries/medications):
No changes
For office use only:
VS: Wt ___ Ht ___ Temp ____ BP _______ P ___ R____
UA: Blood __ Protein __ Nitrite __ Leuko__ Glucose__ Urine culture
UCG:____ WP: BV/Y/Trich Hemoccult: ___ Hgb:____ BG: ___
PAP GC/Ch STD MMG Colon DEXA U/S Lab______
Sprintec Nuvaring OrthoEvra Depo Provera
Macrobid/Cipro/Bactrim Flagyl/Metrogel Diflucan/Monistat/Nystatin Premarin PV/Prempro
NL Findings
NEURO □ ______________________ PSYCH □ ______________________ HEENT □ ______________________ HEART □ ______________________ LUNGS □ ______________________ EXT □ ______________________ ABD □ ______________________ BRSTS □ ______________________ PELVIC □ ______________________ Uterus ant/mid/post/absent


Health & safety data sheet

ECO – INSECTICIDE (1 hour Re-entry) DIRECTIONS: APPLICATIONS: Brush and coarse spray Apply 1 litre of diluted product per 3-4m² of surface. DIP: Dip wood in diluted product for a minimum of 3 minutes. Contains: Permethrin 20% (w/w) Content: 1 x 125g Sachet HSE: 7830 Health & Safety: See Below. Identification of Substance and Supplier Product Description : Insecticide


Isotretinoin SCP contains the active ingredient isotretinoin Consumer Medicine Information What is in this leaflet 6. you have very high fat levels Ask your doctor if you have any (cholesterol, triglycerides) in questions about why Isotretinoin your blood SCP has been prescribed for you. 7. you have hypervitaminosis A It does not take the place of tal

Copyright © 2010-2014 Metabolize Drugs Pdf