Date: ______________________________________________ Date of birth: ___________________________________________
Name: ______________________________________________ Alias/ Nicknames: _______________________________________
Main Reason for visit: ______________________________________________________________________________________
MEDICAL HISTORY: (note year diagnosed with details)
Single Married Widowed Divorced Separated Occupation: _____________________________________ Years of education/highest degree: ________________ c Cancer (____________________) _______________________________ Tobacco Use:
c Chronic eye/ear/nose disorders _______________________________ Cigarettes: c Never c Quit year ________________ c Current smoker: packs/day ____ # of years _______ Other Tobacco: c pipe c cigar c snuff c chew Are you interested in quitting? c Yes c No Drink caffeine: c Yes c No Cups per day _______
Alcohol Use:
Is your alcohol a concern for you or others? Drug Use:
Have you used any recreational drugs? c Yes c No Have you ever used needles to inject drugs? SURGERIES (major) (Note Year)
c Abdominal ________________
Sexual Activity:
Birth Control method: ______________ c none needed Have you ever had a sexually transmitted disease(s) Other Concerns:
Are you interested in being screened for sexually Weight: Is your weight a concern?
Diet: How do you rate your diet? c Good c Fair c Poor
Exercise: Do you exercise regularly?
Year last done
What kind of exercise?___________________________________ How long (minutes) ___________ How often? ______________ Safety: Is violence at home a concern for you? c Yes c No
Have you completed a living will or
durable power of attorney for health care?
MEDICATIONS: Prescription and non-prescription medicines, vitamins, home remedies, birth control pills, herbs:
Name ___________________________________________ HERITAGE
MRN ____________________________________________ PATIENT HISTORY FORM
Date of Birth _____________________________________ ALLERGIES OR REACTIONS TO MEDICINES / FOOD / OTHER AGENTS:
Please note if you have had any of
Check all that apply
the following immunizations
(Note Year)
major illness (Year)
Date of last menstrual period: _____________________ Do you have any of the following problems:
# of pregnancies: ________ # of children: __________ Pap smears: c normal Date_____ c abnormal Date_____ Sexual concerns (getting or keeping an erection) Do you take any of the following:
Progesterone (Provera): c Yes c No c Past Name ___________________________________________ HERITAGE
MRN ____________________________________________ PATIENT HISTORY FORM
Date of Birth _____________________________________


„der kleine unterschied“

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Medical Oxygen 99.5% Consumer Medicine Information What is in this leaflet? This leaflet answers some common questions about Medical Oxygen. It contains only some information, and does not take the place of talking to your doctor or appropriate healthcare professional. All medicines may assist you, but sometimes there are risks. Your doctor or healthcare professional has we

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