Microsoft word - adult physical form.doc

5 6 5 6 B E E C A V E S R D . , S T E E 2 0 0 ♦ A U S T I N , T X 7 8 7 4 6 ♦ ( 5 1 2 ) 3 2 8 - 8 8 8 0 ADULT DATABASE
NAME: ______________________________________ DATE OF BIRTH: _________________ DATE: ________________ AGE:________ SEX: MALE FEMALE Why have you come to see the doctor today? _______________________________________________ _________________________________________________________________________ (check all that apply):
Other:______________________________________ Other:______________________________________ GYN (WOMEN ONLY)
Age Menses began: _____ Date of Last Menstrual Cycle:___________ Birth Control Method using now: ________ Total # Pregnancies: ____ Full term pregnancies: ____ Living children:_____ Miscarriages:_____ Abortions:_____ Date of last Pap smear? __________Ever abnormal Pap?__________ Date of last mammogram? _______________ Do you perform regular monthly self breast exams? _______ VACCINES & CHILDHOOD DISEASES: (Please check all that you have had): Childhood vaccines
Pneumococcal (pneumonia) vaccine Hepatitis B vaccine Tetanus (most recent year): ________ LIST ALL HOSPITALIZATIONS, SURGERIES OR SERIOUS ILLNESS AND GIVE DATES

__________________________________ _____ __________________________________ _____ __________________________________ _____ __________________________________ _____ __________________________________ _____
REGULAR MEDICATIONS (include vitamins, over the counter, birth control, herbal meds,)
(Example: Tagamet, 400mg, one 2 times a day)
Allergies/reactions to medications, food, latex, etc.: NAME ___________________________________________
DATE __________________
Age Medical Problems (List) and Cause of Death if Deceased Deceased?
r ____ __________________________________________________________________ @ age___ r ____ __________________________________________________________________ @ age___ r ____ __________________________________________________________________ @ age___ r ____ __________________________________________________________________ @ age___ r ____ __________________________________________________________________ @ age___ r ____ __________________________________________________________________ @ age___ n ____ __________________________________________________________________ @ age___ ____ __________________________________________________________________ @ age___ Has any member of your family had (check all that apply): Please explain any checked above:____________________________________________________________________ What is your occupation? ______________________________________________________________________ Marital Status: HIV/ Hepatitis risk factors: (check below) ( or check here if you do not wish to comment) Tattoos Homosexual contact IV drug use Multiple sexual partners Blood Transfusion If Current use: (Packs/day: ______ How many years? ______) Movitated to quit? Y N
If Previous use: (Quit when? _____ Smoked/Dipped how many years? _________)
How many drinks/week?: _________________________________
Explain: _______________________________________________ Diet: Good (low cal, low fat, high fiber). Average They know me by name at McDonalds. How many caffeinated drinks/ day? ___________________________________________________________________ Exposure to toxic chemicals: __________________________________________________________________________
Foreign travel in the past 6 months (Where?):_____________________________________________________________
Exercise Routine (what, how much, & how often):_______________________________________________________
Major Changes, stresses: _____________________________________________________________________________

Have you signed for organ donation? ________
Do you have a living will?________ (If not, please ask if you would like us to provide you with one.)

The above is complete and true to the best of my knowledge.

Sixteen Americans die each and every day because there aren’t enough available organs to save their lives. Please donate.



GEBRAUCHSINFORMATION: INFORMATION FÜR DEN ANWENDER Azela-Vision® MD sine 0,5 mg/ml Augentropfen Zur Anwendung bei Erwachsenen und Kindern ab 4 Jahren Lesen Sie die gesamte Packungsbeilage sorgfältig durch, bevor Sie mit der Anwendung dieses Arzneimittels beginnen, denn sie enthält wichtige Informationen für Sie. • Wenden Sie dieses Arzneimittel immer genau wie in dieser Packungsbeil

Erwerb und vererbung von liegenschaften im ausland

Erwerb und Vererbung vonLiegenschaften im Ausland Immer mehr Menschen können es sich leisten, in Sondertestament) nicht der bessere Weg ist, muss in Frankreich, Italien oder Spanien ein Haus oder eine jedem Einzelfall überprüft werden. Viele Eigentü- Wohnung zu erwerben. Schon der Kauf einer Lie- mer wenden sich an lokale Notare, Rechtsanwälte genschaft im Ausland ist mit z

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