Cool site pour acheter des pilules http://achetermedicaments2014.com/ Ne pas se perdre venir sur.

Lincolngi.com

LINCOLN SURGERY ENDOSCOPY SERVICES
Patient Name:_________________________________________ Your Family Doctor is:___________________________
Reason for today's exam:
Height: ________ Weight: _________
Please list all medications, including over-the-counter and herbal remedies below.
Medicine
Why Taking
Medicine
Why Taking
**List all ALLERGIES including type of allergy reaction: (example: Sulfa-Rash)
**Do you take any of the following Anticoagulants? (Circle) Yes No
Coumadin Plavix Heparin Xarelto Pradaxa Eliquis LAST TAKEN_________
**Do you take any NSAIDS and/or Arthritis medications? (Circle) Yes No
Aspirin Ibuprofen/Advil Aleve/Naproxen Excedrin Toradol
Alka Selzer Bextra Celebrex Relafen Feldene Vioxx
Indocin Lodine Mobic Other _______________ LAST TAKEN____________
**Do you take any of the following MAO inhibitors? (Circle) Yes No
Azilect/Rasagiline Marplan/Isocarboxazid Nardil/Phenelzine

Parnate/Tranylcypromine Eutonyl Eldepryl/Emsam/Zelapar/Selegine
Do you have or have you had in the past? (Please CIRCLE all that pertain)

DIGESTIVE SYSTEM
Heart Disease/Problems
Rectal Bleeding/Blood in Stools
Heart Attack Year_______
Abdominal Pain
Rhythm Problem/Irregular Heart Beat
Recent Change in Bowel Habits
High Blood Pressure
Unintentional Weight Gain____ or Loss____
Low Blood Pressure
Nausea or Vomiting
Pacemaker or Defibrillator
Heartburn
History of Stroke/TIA
Difficulty Swallowing/Food Getting Caught
Other________________________________________
Hepatitis
RESPIRATORY/LUNGS
Crohns or Ulcerative Collitis
Breathing or Lung Problems
Other____________________________________________
NERVOUS SYSTEM
COPD/Emphysema
Seizures
Sleep Apnea
Muscle Weakness/Tingling (Location)_______________
Shortness of Breath
Nerve Injury or Paralysis
Currently Smoke _________Amount daily
Back or Neck Problems
Other_________________________________________
Other____________________________________________
Please see reverse side for more questions.
Rev. 9/13, 8/13 (barcode only), 6/13, 11/12, X:\LS Endoscopy Services\Forms\GI Chart Forms\Health History 5/12 (title only), 9/09, 5/09, 10/07, 4/07 LINCOLN SURGERY ENDOSCOPY SERVICES
INFECTIONS
Bleeding or Clotting Disorders
Diabetic
Kidney Problems
ORAL CAVITY
Thyroid Problems
Wear Dentures
History of Recreational Drug Use
Partial Plate
Alcohol Use How Often______________________
Loose Teeth
Glaucoma-Narrow Angle
Difficulty Opening Mouth
FEMALE PATIENTS
History or Current Cancer
Currently Pregnant
Location___________________________________
Currently Breast Feeding
Is there any other pertinent information that we need to know? If so please list below
Please list past surgeries and approximate year performed:
Have you ever had this or any of the following tests before? Please state approximate year.
_____Colonoscopy
_____Flexible Sigmoidoscopy (Flexi)
_____Upper Gastrointestinal Endoscopy (EGD)
_____Esophageal Dilation

Were there any problems?________________________________________________________________________
Because of sedation, you will not be able to drive or return to work for the remainder of the day.
Who will be driving you home following your procedure?_____________________________________________
(If your procedure does not involve sedation please disregard above.)
Do you have and Advance Directive (Living Will/Power of Attorney for Healthcare)? Yes_____ No_____
The information I have provided is accurate to the best of my knowledge.
Patient Signature:________________________________________
Reviewed by:______________________________________________
Advance Directive on chart ____ yes ____ no Please see reverse side for more questions.
Rev. 9/13, 8/13 (barcode only), 6/13, 11/12, X:\LS Endoscopy Services\Forms\GI Chart Forms\Health History 5/12 (title only), 9/09, 5/09, 10/07, 4/07

Source: http://www.lincolngi.com/Health_History_Questionnaire.pdf

Naj2503-body.indd

Unauthorized uses of copyrighted materials are prohibited by law. The PDF file of this article is provided subject to the copyright policy of the journal. Please consult the journal or contact the publisher if you have questions about copyright policy. ABSTRACT : The Venus’ fly trap ( Dionaea muscipula Ellis) is a unique carnivorous plant listed as a Species of Concern within the nativ

Microsoft word - document

North Carolina Society of Oral and Maxillofacial Surgeons Office Anesthesia Evaluation Form A. PERSONNEL 1. ACLS Certificate - (Please have doctor's ACLS Certification available) 2. List of surgical staff's credentials, (OMFSAAP, BLS): B. RECORDS Please have available five charts of patients who have been treated in your office with IV sedation or general anesthesia. Charts m

Copyright © 2010-2014 Predicting Disease Pdf