Patient Profile Please submit this form to our Corporate office at: Raleigh Endoscopy Center 2417Atrium Dr Ste 101 Raleigh, NC 27607 or fax 919-791-2061
Name (print):________________________________ Date of Birth:___________ Procedure Date:____________ Emergency Contact:____________________________Relationship:_______________ Phone #:______________ Primary Care Physician:_________________________Reason for Procedure:_____________________________
Drug Allergies & Reaction:____________________________________ LATEX ALLERGY: Y / N ___________________________________________________________ PLEASE LIST ALL MEDICATIONS YOU TAKE, PRESCRIPTION AND NON-PRESCRIPTION Medicine & Dose-Reason Taken Medicine & Dose-Reason Taken Medicine & Dose-Reason Taken
___________________________ _________________________ _________________________
___________________________ _________________________ _________________________ ___________________________ _________________________ _________________________ BLOOD THINNERS: Do You Take: Aspirin, BC powder, Aleve, Motrin, Ibuprofen, Vitamin E Blood Thinners Such As: Coumadin Warfarin Plavix Levonox or Ticlid? Y / N MEDICAL HISTORY HEIGHT__________ WEIGHT____________ PLEASE CIRCLE IF YOU HAVE OR HAVE HAD ANY OF THE FOLLOWING:
CARDIAC: High Blood Pressure High Cholesterol Mitral Valve Prolapse Irregular Heart Rate Angina Heart Disease (TYPE)____________________ Stent Pacemaker Heart Attack (MI) Congestive Heart Failure PULMONARY: Asthma Emphysema COPD Sleep Apnea GI: Acid Reflux Barrett’s Esophagus Colitis / Crohn’s Colon Polyps Colostomy Ulcers Diverticulosis / Diverticulitis Colon Cancer GU: BPH Urinary Incontinence KIDNEY/ENDOCRINE: Diabetes Kidney Failure / Dialysis Thyroid Problems NEUROLOGIC/MUSCULAR:Stroke Parkinson’s Migranes TIA’S Seizures: Date Of Last Seizure________ PSYCHOLOGIC: Depression Anxiety Mental Illness (type)_______________________________________ AUTOIMMUNE: Rheumatoid / Osteo Arthritis Lupus HIV/AIDS MISC: Anemia Bleeding Disorder Cancer (type): ______ Radiation / Chemotherapy Date: _______________ Pregnant Y / N Breast Feeding Y / N OTHER ILLNESSES NOT LISTED:________________________________________________________________
Do you have to take antibiotics before a medical or dental procedure? Y / N .
FAMILY MEDICAL HISTORY LIST FAMILY MEMBER THAT HAD THE FOLLOWING DISEASE (Immediate family only)
Cancer: Esophageal_____________ Colon____________ Stomach______________OTHER___________________ Diabetes_______________ High Blood Pressure ______________ Heart / Lung Disease______________________
ENDOSCOPY/SURGICAL HISTORY
________________________________________
__________________________________________
________________________________________
__________________________________________
________________________________________
__________________________________________
Have you ever had any problems with anesthesia? Y / N __________________________________________
SOCIAL HISTORY
Do You Smoke? Y / N # Packs/day________ Smokeless Y / N (amount)_______________ Alcohol use: Never Occasionally Daily (# drinks/day)_________________ Rev 09-09
J. Vet. Anim. Sci. (2012), Vol. 2: 40-46 Antimicrobial Resistance Profile of Salmonella Serovars Isolated from Chicken † Department of Animal Product Technologies, Department of Veterinary Medicine, ‡ Faculty of Animal Husbandry and Veterinary Sciences, Sindh Agriculture University, Tandojam, Pakistan ABSTRACT The study was designed to investigate the prevalence and an
Dear Doctor: Thank you for referring your patient to the Newport Beach Anticoagulation Clinic (NBAC). Please complete and sign the order below. Your signature indicates that you are requesting the Anticoagulation staff to manage your patient according to Newport Beach Anticoagulation Clinic Coumadin Titration – Standard Procedure. If your patient is unable to comply with the clinic protocol (i
Patient Profile