Medical History
Name: _______________________________________ Date of Birth: _____-_____-_____ Today’s Date: _____-_____-_____ Who referred you? ___________________________________ Family Doctor: ____________________________________ What type of work do you do? (if retired, what did you do?) ______________________________________________________ Please list any medications you take or use, including eye drops, vitamins, nutritional supplements, herbal remedies, aspirin, and over-the-counter medications: (please use the back of the page if necessary) _____________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ Do you take any blood thinners: □ Yes □ No
If yes, which one(s)? □Aspirin (including baby aspirin) □ Coumadin (warfarin) □Plavix □Aggrenox
□NSAIDs (Advil, Ibuprofen, Naproxen, etc) □Other:______________
Do you currently have or recently had: Y N Allergy or sensitivity to latex→ what reaction? ______________________
Y N Intolerance or allergy to dental anesthesia or other numbing medications
Name of Pharmacy: ____________________________________Address: _______________________________________
Do you have any allergies to medications? □ Yes □ No If Yes, please list medication and reaction below. DRUG ALLERGIES REACTION ____________________________________ □hives/rash/itching □swelling □shortness of breath □other:____________ ____________________________________ □hives/rash/itching □swelling □shortness of breath □other:____________ ____________________________________ □hives/rash/itching □swelling □shortness of breath □other:____________ □ I have more allergies than I can list above Review of Systems:
Y N New, changing or worrisome skin spot(s) Medical History: Have you had, or do you have, any of the following?
Y N Autoimmune disease→ type:______________ Y N Cancer→ type:_______________ Have you ever had a blistering sunburn? □ Yes □ No
When you are exposed to the sun, does your skin (choose one):
Surgery History:
Do you take antibiotics before teeth cleaning or surgery? □ Yes □ No
Have you ever had Mohs surgery for a skin cancer?
Family History: Has anyone in your immediate family had any of the following? If yes, please list their relationship to you.
□ My family history is not known to me.
Y N Abnormal moles_________________________
Y N Autoimmune disease ( □lupus □rheumatoid arthritis □thyroid problems □other)________________________
Social History:
Do you use sunscreen? □ Daily □ When outside for any length of time □ Often □ Sometimes □ Never
Do you visit tanning beds? □ Yes □ No
Do you smoke? □ Yes □ No If yes, for how long and how much?:_____________________________________
Do you drink alcohol? □ Yes □ No If yes, how much? _________________________________
(Females Only) Are you pregnant or trying to become pregnant? □ Yes □ No Are you breast feeding? □ Yes □ No
(Females Only) Are you taking birth control pills or using other methods for birth control? □ Yes □ No
If yes, what method(s): □birth control pills □IUD □NuvaRing □Depo Provera □Other:_________________________


Bsaci factsheet - milk allergy

Cow’s milk allergy (1 of 2) Some reactions to cows’ milk involve themedicine, the term cow’s milk allergy isonly used to describe reactions involvingfood labels every time you shop – even ifreactions are normally called cow’s milk Mild to moderate milk allergy can be found in some unlikely foods. Cow’s milk allergy is common in infantsreaction. Lactose (milk sugar) is u

Labeling of antibiotics for infection diagnosis The high impact of infection on daily clinical prac- tice has promoted resear University Hospital of Bellvitge-IDIBELL oday, 67 MEDICA ch into better and more accu- rate diagnostic and therapeutic methods. Localizing inflammation/infection with nuclear medicine tech- niques began over 40 years ago. T AGa-scintig- raphy, 99mTc-

© 2010-2017 Pharmacy Pills Pdf