Dr. Howard F. Cooke, D.M.D., M.S. My Medication Information
Patient’s Name:________________________________________ Today’s Date ______________________
Primary Care Physician’s Name ___________________________ Phone Number ______________________
Pharmacy (with location) _________________________________ Phone Number _____________________
MEDICATIONS: Are you allergic to, sensitive to, or had a bad reaction to: (Circle Yes or No)
Local Anesthetic (Novocaine, etc.) Yes No
List any other medications you are allergic to: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ ARE YOU USING OR TAKING ANY OF THE FOLLOWING? (Circle Yes or No)
Other Heart Medicine ___________________
Tranquilizers (Valium, Anti-Depressants) Yes
Antihistamines or Decongestants (Seldane)
Aspirin or Ibuprofen (Motrin, Naprosyn, etc.)
Digitalis, Inderal, Nitroglycerin, Calcium Channel
Yes No If yes, how much daily?___________________
LIST ALL MEDICATIONS YOU ARE CURRENTLY TAKING: Prescriptions and over-the-counter medications (ie. aspirins, antacids), herbal supplements (ie. ginseng, gingko). Include all medications taken as needed (ie. nitroglycerin, inhalers, and allergy medications).
Are you now under a physician’s care, or have you been during the past 5 years, for a particular condition? Yes No
If so, what for?_____________________________________________________________________________________________
Have you had any serious illness, operations, or hospitalizations during the past five years?
If so, describe _____________________________________________________________________________________________
Have you had any implant surgery done? List types & date _______________________________________________
Have you ever taken any street/recreational drugs?
Have you ever taken any form of Redux or Fen/Phen?
Do you take/have you taken radiation or chemo for cancer?
Are you pregnant, nursing a child, or planning pregnancy?
DO YOU HAVE OR EVER BEEN DIAGNOSED WITH? (Circle Yes or No)Heart Attack/Heart Surgery
I allow you to give my clinical information to, or answer questions from: (please list all that apply) Name of Person(s)
Relationship to patient (ie. spouse, parent, child, etc.)
I certify that I have read and understand the questions above and the above information is current and correct. I will not hold my surgeon or any of their staff responsible for any errors or omissions that I have made in the completion of this form.
___________________________________________________________________ __________________________________ Patient/Legal
___________________________________________________________________ __________________________________ Clinical
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Kampala, Uganda Africa Basic Information Sheet Travel Expenses: Cost Per Person Total Uganda Trip (with Fund Raiser participation) $1,220.00 ***Price includes Gratuity for the Staff of the Missionaries*** Optional Safari (Depending on the number) ***The above pricing is based on 2013 pricing and is subject to change*** If you want to see your sponsor child(ren) an additional c