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HEALTH HISTORY-TO BE COMPLETED BY PATIENT Medical Problems- Please indicate if you are currently experiencing any of the following: □ Anemia □ Chronic lung disease □ Fibromyalgia □ Irritable bowel syndrome □ Stomach/duodenal ulcer Surgeries/Procedures- Please indicate if you have previously had a surgery or procedure: □ NONE Marital Status: □ Single □ Married □ Divorced If you’ve smoked previously, when did you stop? History of Heart Disease (heart attack, heart failure)? □ Yes □ No who: History of High blood pressure? □ Yes □ No who: History of Diabetes? □ Yes □ No who: History of Crohn’s disease or ulcerative colitis? □ Yes □ No who: Copyright 2009 Advanced Gastroenterology Allergies: NONE Aspirin Morphine Penicillin Sulfa Versed Valium Other:
GI Medications- Please indicate if you are currently taking any of the following: NONE

Other Medications- Please include the STRENGTH & DOSAGE:

Review of Systems-
Please indicate if you are currently experiencing the following:
General: □ fevers, □ chills, □ sweats, □ anorexia, □ fatigue, □ malaise, □ weight loss
□ blurring, □ diplopia (double vision), □ irritation, □ discharge, □ vision loss, □ eye pain
□ earache, □ ear discharge, □ tinnitus (ringing in ear), □ decreased hearing, □ nasal congestion,
□ nosebleeds, □ sore throat, □ hoarseness, □ dysphagia (difficult swallowing)
□ chest pains, □ palpitations, □ syncope (passing out), □ dyspnea on exertion (shortness of breath),
□ orthopnea (shortness of breath when lying down), □ peripheral edema (leg swelling)
□ cough, □ dyspnea (shortness of breath), □ excessive sputum, □ hemoptysis (coughing up blood),
□ wheezing
□ nausea, □ vomiting, □ diarrhea, □ constipation, □ change in bowel habits, □ abdominal pain, □ melena
(black stool), □ hematochezia (rectal bleeding), □ jaundice (yellow skin) □ heart burn
□ vaginal discharge, □ incontinence, □ dysuria (painful urination), □ hematuria (bloody urination), □ urinary
frequency, □ amenorrhea (no menstruation), □ menorrhagia (heavy menstruation), □ abnormal vaginal bleeding, □ pelvic
□ back pain, □ joint pain, □ joint swelling, □ muscle cramps, □ muscle weakness, □ stiffness, □ arthritis
□ rash, □ itching, □ dryness, □ tattoo
□ transient paralysis, □ weakness, □ seizures, □ syncope (passing out), □ tremors, □ vertigo

□ depression, □ anxiety, □ memory loss, □ suicidal ideation, □ hallucinations, □ paranoia
□ cold intolerance, □ heat intolerance, □ polydipsia (excessive thirst), □ polyuria (excessive urination)
□ abnormal bruising, □ bleeding, □ enlarged lymph nodes
□ urticaria (itching), □ hay fever, □ HIV exposure, □ eczema
Copyright 2009 Advanced Gastroenterology


Case #1 – abdominal pain, high-grade ureteral obstruction vs

BCEM Sample Case #1 – Abdominal pain, High-grade Ureteral Obstruction vs. Renal Vein Thrombosis Patient: #1 Date of ED Service: Age: 15 year-old male Admitting Complaint: Abdominal Discharge Diagnosis: Abdominal pain, high-grade ureteral obstruction vs. renal vein thrombosis HISTORY Patient is a 15 year-old Native American teenager who arrives at the Emergency

Microsoft word - wellbutrin xr2.doc

Wellbutrin XR (langwerkend bupropion) voor ADHD Door Sandra Kooij Bron: Nieuwsbrief Kenniscentrum ADHD bij volwassenen, nummer 3, jaargang 9, december 2007 Wellbutrin XR (langwerkend bupropion) is recent geregistreerd voor depressie en wordt nu, met artsenverklaring voor die indicatie vergoed (zie Het middel remt de heropname van zowel noradrenaline als dopamine

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