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Microsoft word - general_medical_info._revised

General Medical Information

Name: _________________________________Date: ______________Age: __________
PAST MEDICAL HISTORY
YEAR

ILLNESSES
________ ( ) Heart trouble (angina__) (heart attack ___) (Heart failure ___) (Heart murmur __) (valve ________ ( ) High blood pressure ________ ( ) Stroke ________ ( ) Ulcers (stomach ___) (duodenal___) (colon___) ________ ( ) Diabetes (high blood sugar) ________ ( ) Liver disease (hepatitis___) (A___) (B___) (Cirrhosis ___) Other______________________________ ________ ( ) Kidney disease (stones ___) (infections ___) other ____________ ________ ( ) Lung disease (emphysema ___)(TB___)(chronic bronchitis ___)(cancer___) (frequent pneumonia___)(asthma___)Other_______________________ ________ ( ) Blood disorders (anemia___) (leukemia ___) (bleeding tendency ___)
Other _____________________________________________
________ ( ) Eye disease (glaucoma___) Other_______________________
________ ( ) Arthritis (degenerative___) (rheumatoid___) (gout ___)Other___________
________ ( ) Cancer, Type ______________________________________
________ ( ) Psychological difficulties (depression___) (psychosis ___) )Other________
________ ( ) Other major illness_____________________________________________
________ ( ) No major illnesses
YEAR
SURGERIES
________ ( ) Hysterectomy (total___) ( partial___) ________ ( ) Biopsy (result & type__________________________) ________ ( ) Fractures explain_________________________________________ ________ ( ) Other _________________________________________________
MAJOR INJURIES/ ACCIDENTES MAYORES
( ) Auto or cycle accidents:________________________________________________
( ) NO MAJOR INJURIES
HOSPITALIZATIONS:__________________________________________________



MEDICATIONS/MEDICINAS (Names & Dosages,
if you have more please list on the back of the page.)
( ) ________________________________________________________________
( ) ________________________________________________________________
( ) ________________________________________________________________
( ) ________________________________________________________________
( )
Birth Control Pill __________________________________________________
ALLERGIES
Describe Reaction:
( ) Penicillin (rash___) (breathing problems___) (required hospitalization___) (nausea/vomiting__)
(rash___) (breathing problems___) (required hospitalization___) (nausea/vomiting__) ( ) Keflex (rash___) (breathing problems___) (required hospitalization___) (nausea/vomiting__)
( ) Codeine (rash___) (breathing problems___) (required hospitalization___) (nausea/vomiting__)
( ) Other ________________________________________________________
( ) None ________________________________________________________
FAMILY MEDICAL HISTORY/HISTORIA MEDICA FAMILIAR
MOTHER: ( ) Alive & well ( ) Alive but suffers with:________________ Age____
( ) Deceased / Cause:________________________ Age of death ________
FATHER: ( ) Alive & well ( ) Alive but suffers with:________________ Age____
( ) Deceased / Cause:________________________ Age of death ________
SIBLINGS: ( ) Alive & well ( ) Alive but suffers with:________________ Age____
( ) Deceased / Cause:________________________ Age of death ________
Members of my family: (brothers, sisters, grandparents, aunts, uncles) suffer from the following:
( ) Stroke
( ) Diabetes ( ) Back problems ( ) Heart trouble
SOCIAL HISTORY/HISTORIA SOCIAL
1. Married ___, Separated ___, Divorced ___, Widow-Widower____, Single______
No. of children at home ______ No. of children away ______
2. I work as/ am retired from______________________________________________________
3. I drink alcohol: None____ Daily____ Socially______
Beer_____ Wine_____ “Hard drinks”_______
I drink too much_______________________________
Others think I drink too much______
4. I smoke: None____ Cigarettes_____ Pipe________ Cigars____
I smoke_____ packs______ a day, for_____ years.

Source: http://medicalsleep.com/Documents/General_Medical_Info.pdf

Microsoft word - rxedo_select_120107_.doc

Non-Preferred EDO Preferred Brands ($$$) Alternatives ($ or $$) * Preferred Drug List Dear Member: Please review this Preferred Drug List (PDL) with your physician at the time he or she writes your Formulary Disclaimer: prescription. This PDL, which includes both brand Please be sure your prescription drug benefit is offered and generic medications, is not a c

Microsoft word - soremouth.doc

DIFFERENTIAL DIAGNOSIS OF ACUTE AND CHRONIC SYMPTOMATIC ORAL ULCERATIONS Acute and chronic ulcerations represent the most common symptomatic mucosal pathoses encountered by oral health care practitioners. Every clinician should have an organized approach to these problems which will be encountered frequently. The first step in all cases should be to divide and conquer. The ulcerations

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