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Patient Name:_________________________________________ Your Family Doctor is:___________________________
Reason for today's exam:
Height: ________ Weight: _________
Please list all medications, including over-the-counter and herbal remedies below.
Why Taking
Why Taking
**List all ALLERGIES including type of allergy reaction: (example: Sulfa-Rash)
**Do you take any of the following Anticoagulants? (Circle) Yes No
Coumadin Plavix Heparin Xarelto Pradaxa Eliquis LAST TAKEN_________
**Do you take any NSAIDS and/or Arthritis medications? (Circle) Yes No
Aspirin Ibuprofen/Advil Aleve/Naproxen Excedrin Toradol
Alka Selzer Bextra Celebrex Relafen Feldene Vioxx
Indocin Lodine Mobic Other _______________ LAST TAKEN____________
**Do you take any of the following MAO inhibitors? (Circle) Yes No
Azilect/Rasagiline Marplan/Isocarboxazid Nardil/Phenelzine

Parnate/Tranylcypromine Eutonyl Eldepryl/Emsam/Zelapar/Selegine
Do you have or have you had in the past? (Please CIRCLE all that pertain)

Heart Disease/Problems
Rectal Bleeding/Blood in Stools
Heart Attack Year_______
Abdominal Pain
Rhythm Problem/Irregular Heart Beat
Recent Change in Bowel Habits
High Blood Pressure
Unintentional Weight Gain____ or Loss____
Low Blood Pressure
Nausea or Vomiting
Pacemaker or Defibrillator
History of Stroke/TIA
Difficulty Swallowing/Food Getting Caught
Crohns or Ulcerative Collitis
Breathing or Lung Problems
Sleep Apnea
Muscle Weakness/Tingling (Location)_______________
Shortness of Breath
Nerve Injury or Paralysis
Currently Smoke _________Amount daily
Back or Neck Problems
Please see reverse side for more questions.
Rev. 9/13, 8/13 (barcode only), 6/13, 11/12, X:\LS Endoscopy Services\Forms\GI Chart Forms\Health History 5/12 (title only), 9/09, 5/09, 10/07, 4/07 LINCOLN SURGERY ENDOSCOPY SERVICES
Bleeding or Clotting Disorders
Kidney Problems
Thyroid Problems
Wear Dentures
History of Recreational Drug Use
Partial Plate
Alcohol Use How Often______________________
Loose Teeth
Glaucoma-Narrow Angle
Difficulty Opening Mouth
History or Current Cancer
Currently Pregnant
Currently Breast Feeding
Is there any other pertinent information that we need to know? If so please list below
Please list past surgeries and approximate year performed:
Have you ever had this or any of the following tests before? Please state approximate year.
_____Flexible Sigmoidoscopy (Flexi)
_____Upper Gastrointestinal Endoscopy (EGD)
_____Esophageal Dilation

Were there any problems?________________________________________________________________________
Because of sedation, you will not be able to drive or return to work for the remainder of the day.
Who will be driving you home following your procedure?_____________________________________________
(If your procedure does not involve sedation please disregard above.)
Do you have and Advance Directive (Living Will/Power of Attorney for Healthcare)? Yes_____ No_____
The information I have provided is accurate to the best of my knowledge.
Patient Signature:________________________________________
Reviewed by:______________________________________________
Advance Directive on chart ____ yes ____ no Please see reverse side for more questions.
Rev. 9/13, 8/13 (barcode only), 6/13, 11/12, X:\LS Endoscopy Services\Forms\GI Chart Forms\Health History 5/12 (title only), 9/09, 5/09, 10/07, 4/07


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FO GUANG SHAN NAN TIEN TEMPLE RISK ASSESSMENT FOR SCHOOL TOURS Potential risks Activity List hazards/risks related Control Strategies Please list to each activity/program Outline strategies for ensuring visitor safety for this potential risk and the venue 1. Guided 1.1,1.2 &1.3 Wear closed in shoes with non slip sole 1.1 Stairs,


1/6 oldal Dátum: 2007.06.25. Degesch Phostoxin golyó, pellets, Detia Gas Ex-B Kereskedelmi és Szolgáltató Kft. 1089 Budapest, Orczy u. 6. - 1464 Bp. Pf. 1403Telefon: 464-4938, Fax: 464-4991Verziószám: 1.1. (Hu) Degesch Phostoxin tabletta Revízió kelte: 2005.11.12. A készítmény neve: Degesch Phostoxin tabletta/golyó/pellet* cím: Dr. Werner-Freyberg Str. 11. D-69514 La

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