TREATMENT NAÏVE / NEW (B) PRESCRIBING DOCTOR ASSESSMENT PRINCIPLE MEMBER INFORMATION Principal Member’s Initials Principle Member’s First Name Principal Member’s Surname Identity Number Medical Aid Medical Aid Number PATIENT INFORMATION Patient Name Patient Surname Patient Identity Number - - - Dependant Code Contact Telephone Number Allergies – Please tick the following if applicable: Penicillin Sulphonamides Please specify other: ______________________________________________________________________________________________________ CLINICAL EXAMINATION Is the treatment required as a prophylaxis - post exposure Has the patient had: Pancreatitis Liver Disease Kidney Disease Elevated Uric Acid Level CD 4 COUNT ___________________________ mm VIRAL LOAD __________________________________ RNA Copies/ml STD Screen __________________________________________________________________________________________________________________ TB Contacts YES / NO WHO Staging _________________________________________________ TB Treatment, define: _________________________________________________________________________________________________________ Is patient pregnant? YES / NO Date of last test: ______________________________________________________________________________________________________________
Is there any significant cervical and/or auxilliary lymphao anopathy? Is there any abnormal finds on examination of skin? If YES, please define: ______________________________________________________________________ Is oral candidissis present? Is there evidence of recent memory loss or development delays (children)? Are there any other findings on examination? If YES, Please define: ______________________________________________________________________ PLEASE NOTE THAT THE EXAMINATION DETAILS ARE ESSENTIAL FOR REGISTRATION & AUTHORIZATION – KINDLY PROVIDE COPIES OF PATHOLOGY REPORTS IF AVAILABLE. HIV MEDICATION
NAME, STRENGTH & DOSAGE OF MEDICATION CURRENTLY PRESCRIBED MONTHLY QUANTITY PREVIOUS MEDICATION
MEDICATION DURATION OF TREATMENT REASON REASON CODES DISCONTINUATION RESISTANCE B = SIDE EFFECTS Other Medication used on a regular basis: ____________________________________________________________________________________ ______________________________________________________________________________________________________________________________ Has member been hospitalized during the last 12 months YES / NO Date: ______________________________________________________
DOCTOR DETAILS BHF PRACTICE NUMBER: HPC REG NUMBER: PRACTICE POSTAL ADDRESS: PHYSICAL ADDRESS:
CONDITIONS, UNDERTAKINGS & WARRANTIES PATIENT CONFIDENTIALITY All member/patient information disclosed by means of this application will be treated as confidential and wil not be revealed in any form to any party other than the direct employees of Optipharm and the patients Medical Scheme, unless specific written authorization/consent has been given to Optipharm by the patient. IMPORTANT INFORMATION
SEDRAH SELECTIONS PARSHAS BO 5772 BS”D Ch. 7, v. 17: “Hi’nei onochi ma’keh” – Behold I will smite – Many commentators explain the appropriateness of smiting the Egyptians with specifically the ten plagues, as recorded in our and the following parshios. The Kli Yokor offers: 1) The Nile was smitten in response to Paroh’s saying that the Nile was his and he created himself (
MAY 15, 2005 A l l t h e C l i n i c a l N e w s i n S i g h t Punctal plugs plus topical agent maximize dry eye relief Combination offers improvement with less reliance on artificial tears By Cheryl Guttman scores in the three groups ranged from 2 to 2.3 at Dual approach baseline (possible score range, 0 to 4). All groups“Management of dry eye has received increased at-show
TREATMENT NAÏVE / NEW