CONFIDENTIAL PATIENT CASE HISTORY As a multidisciplinary practice providing comprehensive care, we focus on your ability to be healthy. Our goals are: firstly, to address the issues that brought you to this practice; secondly, to treat the cause of your condition (not just treat the symptoms or place a temporary patch over your condition); and thirdly, to offer you the opportunity of improved health potential and wellness services in the future. Answering the following questions will give us a profile of your health, and ensure that we optimise your outcome and deliver treatment excellence. What is your major complaint? _________________________________________________________________ Draw on the sketch below the area(s) where you feel your problem to be.
When did your symptoms start? _________________________________________________________________ Was it a gradual or sudden onset? _________________________________________________________________ Have you had this or a similar problem in the past? _________________________________________________________________ If you are experiencing pain, please tick the words that best describe your pain:
Confidential Patient Case History Form Version 1.0,
Do you get?
needles Since the problem started it is:
About the same Getting better Getting worse
What makes your pain worse? Your pain interferes with: What type of work do you do? __________________________________________________________ Any Bladder or Bowel changes since this episode started? __________________________________________________________ Do you experience any nausea, dizziness, difficulty swallowing, changes in vision, or fainting spells, fever, skin rashes associated with your symptoms? __________________________________________________________ Other health professionals seen for this problem (please list): Medical Doctor____________________________________________________________ Specialist Doctor/Surgeon_____________________________________________________ Physiotherapist/Chiropractor __________________________________________________________________ Other __________________________________________________________________ List any medications you are taking __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ Have you ever taken oral cortisone or prednisone (including asthma medications such as pulmicort, symbicort, flixotide & seretide)? Y/N Are you pregnant? Y/N
Confidential Patient Case History Form Version 1.0,
Do you have or have you ever had?: (please tick)
High blood pressure
Patient’s Signature: _______________ Print Name: ______________________ Practitioner's Signature: _________________ Date: _____________________
Confidential Patient Case History Form Version 1.0,
Responsabile del Centro Emostasi e TrombosiSIMG,Società Italiana di Medicina Generaleper la Sorveglianza degli Anticoagulati (FCSA)SIMG,Società Italiana di Medicina GeneraleLa realizzazione e distribuzione di questo fascicolo è stata resa pos-sibile grazie al contributo di Ravizza Farmaceutici SpA PREFAZIONE La terapia anticoagulante orale (TAO) costituisce un tratta-mento di grande e cr
CONVOCATORIA Y DATOS GENER ALES DEL PROCE SO DE CONTRATACI ÓN S ERVICIO MUNIC IP AL DE AGUA P OTABLE Y AL CANT ARILLADO SANIT ARIO DE C OCHABAMBA - SEMAPA 1. CONV OCATOR IA Se convoca a la p resen tación de p ropuestas para el sig uiente proceso : S ERV ICIO MUNIC IPA L DE AGU A PO TAB LE Y AL CAN TAR ILLA DO S ANIT ARI O DE En tidad Convocan te : CO CHA BAMB A Mo d
CONFIDENTIAL PATIENT CASE HISTORY 
Do you have or have you ever had?: (please tick)