801 Beville Road South Daytona, FL 32119 386-788-2300 Fax 386-756-1697 3 Pine Cone Drive, Suite 105 Palm Coast, FL 32137 386-986-3482 Fax 386-756-1697 PATIENT MEDICAL HISTORY FORM Name:_________________________________________________________________ Date:_______________ Current Health Status: Poor Fair Good Excellent Age:________ Height_______ Weight________ What is the primary reason for today’s visit?_______________________________________________________ Was this and accident? Yes / No Date symptoms first occurred or date of injury:_______________________ If injury, where did the accident occur?____________________________________________________________ What symptoms are you having? (swelling, numbness, pain, etc.)_______________________________________ Has another Doctor treated you for this problem? Yes / No Name of Physicaian:___________________________ What kind of treatment was done?_______________________________________________________________ Do you treat this yourself? (Aspirin, Advil, etc) Yes / No Please list:_____________________________________ Have you ever injured this area before? Yes / No If so, when?_________________________________________ PAST MEDICAL / FAMILY HISTORY
Do you and/or any family member have any of the following conditions: (mark “P” for patient and/or “F” for family member) Anemia/Blood Disorder ___ Heart Attacks ___ Strokes / TIA’s ___ Arthritis Problems ___ Heart Disease ___ Thyroid Disease ___ Cancer ___ Jaundice/Hepaitis ___ Tremmors ___ Chronic Neck/Back Pain ___ Joint Problems ___ Urinary Tract Problems ___ Diabetes ___ Kidney Problems ___ Varicose Veins ___ Dizziness ___ Liver Disease ___ Other__________________________ Epilepsy/Neurological ___ Respiratory Problems ___ Hypertension ___ Seisures ___ Headaches ___ Stomach/Bowel Disorder ___ Please list prior Surgeries & the Date: (If you have a long list we are happy to make a copy for your chart)
Have you recently been hospitalized? Yes / No If yes, Where?___________________ Why?__________________ Do you smoke? Yes / No How much?______ Do you drink alcohol? Never Sometimes Socially Daily Habitual
Do you use Marijuana? Never Sometimes Socially Daily Habitual For Medical Necessity List all Medications (Prescribed and Over-the-Counter. If you have a long list we are happy to make a copy for your chart)
Are You currently taking any Blood Thinners? Yes / No If so, what?_______________________________________ Do you have any allergies to medications? Yes / No If so, what?__________________________________________ Is there anything else the doctor should be aware of?___________________________________________________ _____________________________________________________________________________________________ Signature:_________________________________________________________ Date:______________________
Coastal Patient History - Document Prepared For Coastal Pain Centers by Imagery.cc 03-03-08
XIX FIGO WORLD CONGRESS OF GYNECOLOGY AND OBSTETRICS INDUSTRY-SPONSORED SYMPOSIA Monday, 5 October 2009 13h00-14h15 Ballroom East (CTICC) Contraception and Beyond: Evidence-based Indications for LNG-IUS 1. Wider Use of Intrauterine Contraception - David Grimes 2. The LNG-IUS in Heavy Menstrual Bleeding: First-line Treatment Based on Comprehensive Clinical Data - Anita Nelson3. S
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