Medical History. Relevant physical health conditions reported by the beneficiary or a significant support person. Include name and address of current source of medical treatment. For children and adolescents, the history must include prenatal and perinatal events and relevant/significant developmental history. If possible, include other medical information from medical records or relevant consultation reports;
Medical History. Collect medical history information, including information on all medications used within the past 30 days. Include herbal therapies, vitamins, and all over-the-counter as well as prescription medications. Throughout the subject’s participation, obtain information on any changes in medical health and/or the use of concomitant medications.
Medical History. Physician/Program Name Address Telephone Number Date of last Physical Exam Weight Height Have you ever been hospitalized for a medical (physical) reason? [ ] yes [ ] no Date of Hospitalization What was the reason for your hospitalization? Have you ever had surgery? [ ] yes [ ] no Nature of Surgery Hospital Date Please indicate if you have ever received any of the following testing; if not, please mark with “N/A”. Date Result (if known) and facility preformed at CT Scan (brain) MRI (brain) EEG Neuropsychological Testing Do you have any of the following medical illnesses? No. Yes. Please provide further information AIDS/HIV Blood pressure problem Cancer Diabetes Epilepsy/seizures Gastrointestinal Head Injury (Head trauma Heart disease Kidney disease Liver disease Neurological disease (stroke, neuropathy, headaches etc.) Thyroid disease Musculoskeletal problems Sleep Apnea Other Do you currently have any of these physical symptoms? No Yes. Please provide further information. Bleeding or bruising Cardiac (heart) problem (heart-racing, chest pain, etc.) Diarrhea or constipation Dizziness, lightheadedness or fainting Feel cold or hot Headaches Muscle spasms or weakness Weight change Other EMERGENCY CONTACT Name: Relation: Phone number(s): Patient Signature: Date: Today's date: I I TAK Center for Mental Health HIPAA & Consent Primary Care Physician: Patient's last name: First: Middle Initial: Marital status (circle one): Single / Mar / Div / Sep / Wid Former name (if applicable): Birth date: I I Age: Sex: OM □ F Street address: Home phone no.: Cell phone no.: ( ) ( ) P.O. box: City: State: ZIP Code: Race (check all that apply): □ American Indian or Alaska Native □ Asian Ethnicity □ Hispanic or Latino □ Native Hawaiian or Other Pacific Islander □ Black or African American (check one): □ Not Hispanic or Latino □ White □ Hispanic □ Other Race Social Security No.: ---- --- I E-mail Address: Preferred Pharmacy /Location: By signing below, I acknowledge the following: • I give TCMH (TAK Center for Mental Health) consent to access my prescription history, including all past prescribed medication, in order to verify future prescription refills. • I give TCMH consent to bill my insurance company for any fees related to services provided by their staff, perform reasonable and necessary medical examinations, testing and treatment at the discretion of its healthcare professionals based on their clinical judgment of my condition. • I give TCMH consent to bill me directly for ...
Medical History. All statements concerning my medical history, insurance information and emergency contacts in the medical history that follows are current, accurate, and complete (use additional sheets if necessary). I understand that I am required to carry a complete medical history on my person at all times during the course of the Performance Tour. The following information is a full and correct statement of my medical history:
Medical History. Do you have any medical history, allergies or medications which you would like us to have on record? [ ] No [ ] Yes, explain: TRAVEL INSURANCE: Baggage, accident, medical and trip cancellation/interruption insurance is recommended. Crafty Gemini LLC cannot be responsible for extra expenses due to delays and changes in your itinerary for reasons beyond our control. I understand that I may purchase travel insurance for baggage, accident, medical and trip cancellation/interruption refunds through a travel insurance company (consult with you travel agent) and [ ] I DO or [ ] I DO NOT intend to obtain travel insurance to cover any losses related to the 2018 Crafty Gemini Sewing/Quilting Retreat.
Medical History. I understand that participation in this activity is NOT recommended for persons who have any allergies or medical conditions or problems such as heart condition, seizures, high blood pressure, stomach problems, joint problems, hearing difficulty, breathing condition, diabetes, back problems, vision problems, migraines, dizziness, poor circulation, arthritis, toothaches, past surgery, or any other medical condition or difficulty that would prevent me from safely participating in this event. If I or the participant named below has any of these or other conditions or problems and still chooses to participate in this activity, I assume all risks associated with such participation. Release of Photographs: I understand that photographs and/or videotapes of me and my family members may be taken for use in promoting the City of Xxxxx activities and facilities in future editions of CenterPoint, in a variety of other publications, on signage throughout the Community Center, and for other uses by the City of Xxxxx. I hereby give my permission to use such photographs without compensation to me. With clear knowledge of the risks involved in participation with the indoor rock climbing facility, including, but not limited to those outlined herein, I voluntarily assume all risks associated with participation, known or unknown, and I agree to follow all safety policies and procedures established by the City of Xxxxx for participation with the indoor rock climbing facility. I further certify, acknowledge and agree that the participant named below is of the physical, emotional and mental capability necessary for participation with the indoor rock climbing facility, at the present date and any future date.
Medical History. Patient Name: Date: / / What skin issue are you here for: Are you ALLERGIC to LATEX? YES NO If Yes, explain reaction: Have you ever had a SKIN CANCER? YES NO If YES, Circle Type: MELANOMA BASAL CELL CARCINOMA SQUAMOUS CELL CARCINOMA Is there a FAMILY HISTORY of MELANOMA: YES NO Who? Is there a FAMILY HISTORY of Other SKIN CANCER : YES NO Who? Have you ever been diagnosed with HIGH BLOOD PRESSURE (hypertension) or DIABETES? : YES NO Are you taking ASPIRIN, MULTI-VITAMINS, FISH OIL or HERBAL SUPPLEMENTS?: YES NO Do you currently use Nicotine? YES NO How many yrs? Tobacco Vaping electronic pen Are you ALLERGIC to any medicines? YES NO If Yes, please list: MEDICATION ALLERGY REACTION MEDICATIONS and SUPPLEMENTS/HERBALS you are currently taking : NONE
Medical History. Have you ever had or been treated for (positive answers must be explained below): Yes No Yes No Yes No Convulsions or Seizures Cardiac Angiogram or ECHO Herniated Disc or Sciatica Epilepsy PFO Repair Shoulder Injury Concussion or Head Injury High Blood Pressure Elbow Injury Disabling Headaches Asthma or Wheezing Arm/wrist/hand Injury Loss of Balance/Dizziness Coughing up Blood Hip/Leg/Ankle Injury Severe Motion Sickness Tuberculosis Knee Injury or “Trick Knee” Unconsciousness Shortness of Breath Foot Trouble or Injuries Fainting Spells Chronic Cough Dislocations Wear Contacts/Glasses Pneumothorax Swollen Joints Color Vision Defect Lung Disease or Surgery Broken Bones or Fractures Eye Disease or Injury Gallbladder Disease or Stones Varicose Veins Eye Surgery Stomach Trouble or Ulcers Muscle Disease or Weakness Hearing Loss Stomach Bleeding Numbness or Paralysis Ear Disease or Injury Frequent Indigestion Sleep Disorders Ear Surgery Jaundice Diabetes Perforated Eardrum Liver Disease or Hepatitis Goiter or Thyroid Disease Difficulty Clearing Rectal Bleeding/Blood in Stools Blood Disease Nose Bleed Hemorrhoids (Piles) Anemia: Sickle Cell or Other Airway Obstruction Gas Pains Skin Rash or Disease Hay Fever or Allergies Crohn’s Disease/Ulcerative Colitis Staph Infections Chest Pain Rupture or Hernia Tumor or Cancer Heart Murmur Kidney Disease Claustrophobia Rheumatic Fever Kidney Stones Mental Illness/Depression/Anxiety Heart Attack Protein, Sugar or Blood in Urine Nervous Breakdown Abnormal Heart Rhythm Joint Pain/Arthritis Any Sexually Transmitted Disease Heart Disease Back Strain or Injury Contagious Disease Cardiac Stent or Angioplasty Spine Problems Other Illness or Injury or Any Other Medical Condition For Females ONLY Irregular Menses Painful Menses Pregnancy Last Menstrual Period PLEASE EXPLAIN THE DETAILS OF EACH ITEM CHECKED YES 13. LIST ALL SURGERIES YEAR
Medical History. Current prescribed medications/dosage: Prescribing physician(s): Past hospitalizations, surgeries, medical issues Current medical issues: Allergies: None known Ongoing physical pain? Yes No Frequency? Location? When began? Intensity (0 none -10 extreme) Physical disabilities or limitations of movement, sight, or hearing? Yes No If yes, explain Abuse: History of being sexually abused? Yes No History of being physically abused? Yes No If yes, state relationship to the abuser. Date(s) of abuse Was the abuse reported? Yes No If yes, to whom? Any abuse of any kind to other members of family? Yes No If yes, to whom?
Medical History. Please list the dates of each occasion of sickness absence in the past 3 years. Please give the reason for each absence and the total number of days you were absent on each occasion. Please note this will be substantiated when references are taken up. Do you have any current medical condition which may affect your ability to perform all the duties of the post as described in the Job Description? Yes/No If YES please give details:
