MEDICAL HISTORY Today’s Date:______________
Name:________________________________________________________ Date of Birth:_____/______/__________
Height:_________________ Weight:________________ Primary Care Provider: ____________________________________
Reason for your visit today: ________________________________________________________________________________
Duration:__________________________ Location:_____________________________ Any Pets?:
□ No □ Yes
Symptoms: _____________________________________________________________________________________________
Has this condition changed over time?
□ No □ Yes If yes, how? _______________________________________________
Any past treatment?
□ No □ Yes If yes, what treatment/medication?___________________________________
Any response to treatment?
□ No □ Yes If yes, what? ______________________________________________________
Are you al ergic to any medications? □
No □ Yes If yes, list:
1.___________________________________ 2.________________________________ 3._______________________________
Reaction to allergy:
1.___________________________________ 2.________________________________ 3._______________________________
List al medications you are currently taking and dosage (follow-up patients: if any new medications, please list):

1.___________________________________ 2.________________________________ 3._______________________________
4.___________________________________ 5.________________________________ 6._______________________________
Do you now, or have you ever had any of the fol owing diseases or conditions?
(Please check if self or family member)
List any surgeries you have had:

Do you drink alcohol? □ No □ Yes If yes, ___________drinks per day
Do you bleed easily? □ No □ Yes
Do you smoke?
□ No □ Yes If yes, ___________packs per day For how many years? ___________________
Have you been exposed to HIV? □ No □ Yes Women, are you pregnant or nursing? □ No □ Yes
Have you ever had dental anesthesia (Xylocaine)? □ No □ Yes Any bad reaction? □ No □ Yes
When exposed to sun, do you: □ Tan Only □ Tan and Burn □ Burn Do you, or have you ever used a tanning bed? □ No □ Yes
Do you have a history of any specific skin diseases? □ No □ Yes If yes, please list: _________________________________
Preferred Pharmacy and location: _________________________________ Phone: ___________________________________
Patient/Guardian Signature_______________________________ Provider’s Signature: _______________________________

Source: http://www.midatlanticskinsurgery.com/documents/MedicalHistoryautofill.pdf


A pilot study on a specific measure for sleep disorders in Parkinson’s disease: SCOPA-Sleep P. Martínez-Martín a, E. Cubo-Delgado a,b, M. Aguilar-Barberà c, A. Bergareche d, S. Escalante c, A. Rojo c, J. Campdelacreu c, B. Frades-Payo a, S. Arroyo a, on behalf of the ELEP Group e A PILOT STUDY ON A SPECIFIC MEASURE FOR SLEEP DISORDERS IN PARKINSON'S DISEASE: SCOPA-SLEEP Summary.

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Fachbeitrag Dr. Möbius I. Teil Literaturverzeichnis ANDRIAN, E., GRENIER, D., ROUABHIA, M.: In vitro models of tissue penetration and destruction by Porphyromonas gingivalis. Infect Immun. 72, 4689-4698 (2004) BACHMANN, A.: Der Biofilm ist nur zu managen – die Entfernung ist nicht möglich und nicht sinnvoll. DZW 9, 28-29 (2005) FILOCHE, SK., ZHU, M., WU, CD.: In situ biofilm formati

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