Microsoft word - medical information forms
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
The National Defense Council Foundation Issue Alert ARTEMISININ NEW HOPE FOR MALARIA VICTIMS THE SCOURGE OF MALARIA Malaria is one of the triumvirate of diseases that has devastated the developing world. Along with AIDS and Tuberculosis, it has reached pandemic proportions in Asia and Africa with some 120 million clinical cases reported annually. Although the vast majority of M
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