Colon and Rectal Clinic, P.A.
Patient Name: ________________________ Age: __________ Date of Visit: _________ Height: _______________ Weight: _______ PREVIOUS ILLNESSES (Please list any illness you have had, and the dates of their occurrence) _____________________________________ ________________________________ _____________________________________ ________________________________ _____________________________________ ________________________________ PREVIOUS COLON SCREENING (Please list the most recent colon screenings you have undergone and the dates of their occurrence) Flexible Sigmoidoscopy _________________ Colonoscopy ___________________ Barium Enema ________________________ _______________________________ PAST SURGICAL HISTORY (Please list all operations you have had and the dates of occurrence) _____________________________________ ________________________________ _____________________________________ ________________________________ _____________________________________ ________________________________ MEDICATION (Please list all medications that you are currently taking and their doses. Please include over-the-counter and herbal medications) Please note if you are on the following specifically:
__________________________________________ Plavix Coumadin/warfarin Ticlid Aspirin ____________________________________ __________________________________ ____________________________________ __________________________________ ALLERGIES (Please list any medication you are allergic to and explain the reaction to the medication) No Known Drug Allergies______________ ________________________________ _____________________________________ ________________________________ FAMILY HISTORY (Please list your family member and the disease associated) Colon Cancer ________________________ Other__________________________ Rectal Cancer ________________________ ________________________________ Polyps ______________________________ ________________________________ REVIEW OF SYSTEMS (Do you currently have or had a history of the following? Please check all that apply. If you do not check the box, we assume that the answer is no.) General Cardiovascular Female Reproductive Neurologic/Psychiatric
Recurrent fever High blood pressure
Urologic Eye, Ear, & Throat Male Reproductive
Abnormal stress test Prostate gland problems pregnancies ______
Personal Habits Respiratory Abdominal/GI Endocrine
Difficulty swallowing Nausea/vomiting
Diabetes Asthma ______________________
Hematologic Peptic Ulcer Hormonal abnormalities Anemia Jaundice Rheumatologic Primary Care Doctor Dermatologic Oncologic Rash Other Physicians
I have reviewed the above information with the patient on this date. All boxes which are not checked are either negative or N/A. Physician’s Signature________________________________
ANTIBIOTHERAPIE PAR VOIE GENERALE EN PRATIQUE COURANTE: infections ORL et respiratoires basses ANGINES AIGUËS I. Introduction L’angine aiguë est une pathologie banale et fréquente qui entraîne annuellement en France environ 9millions de diagnostics et 8 millions de prescriptions d’antibiotiques (1). L’impact écologique d’une telle prescription d’antibiotiques justi
SUCRALFATE TABLETS, USP DESCRIPTION Sucralfate is an ␣-D-glucopy- ranoside, -D-fructofuranosyl-, octakis-(hydrogen sulfate), alu- minum complex. Tablets for oral administrationcontain 1 g of sucralfate, USP. nesium stearate, and colloidalsilicon dioxide. CLINICAL PHARMACOLOGY Sucralfate is only minimally absorbed from the gastrointestinal tract. The small amounts of the sulfated