Manual

Attachment 11A
Page 1 of 2
RIVERSIDE COUNTY DEPARTMENT OF MENTAL HEALTH
ADULT MEDICAL HISTORY SUMMARY
Part I – TO BE COMPLETED BY PATIENT OR PATIENT INFORMANT (Please Print)

Patient’s Name:

_________________
(First) (Middle) (Last)
(Maiden)
Informant
Patient/Relationship:
_________________

Current Physician:

_________________
(Address/City)

Date of Last Physical: ___________________

Do you have allergies? Yes No

PLEASE CHECK ALL OF THE FOLLOWING WHICH YOU HAVE HAD IN THE PAST:

_________________
_________________
SUBSTANCES YOU ARE ALLERGIC TO:
______________________________

DESCRIPTION
ALLERGIC
RESPONSE/NATURE
REACTION:
______________________________
WITHIN THE PAST YEAR HAVE YOU TAKEN PRESCRIBED OR OTHER MEDICATIONS FOR:

Nutrition/Weight Problem? Name: ______________________________________ Currently Using? Nerves/Anxiety/Depression? Name: ______________________________________ Currently Using? Name: ______________________________________ Currently Using? Name: ______________________________________ Currently Using? Are you taking, or have you taken Antabuse?
Consumer Signature:
Attachment 11A
Part II – HISTORY TAKING FOR STAFF USE ONLY (Use Additional Sheets if Necessary)
SIGNIFICANT PAST ILLNESS, ACCIDENTS, HOSPITILIZATION, and MEDICAL PROBLEMS: SIGNIFICANT FAMILY HEALTH HISTORY AND PROBLEMS: ________________________________________________________________________________________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ 5. PAST ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ 6. OTHER MEDICATIONS (Includes Prescription and Non-Prescriptive Drugs): ____________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________________________________________________________________________________ CURRENT USE OF ALCOHOL AND/OR STREET DRUGS: ________________________________________________________________________________________________________________________________________________________________________________________________________________________ 8. PAST USE OF ALCOHOL AND/OR STREET DRUGS: ________________________________________________________________________________________________________________________________________________________________________________________________________________________ IF ENTRIES ARE MADE TO EITHER QUESTION 7 OR QUESTION 8, PLEASE COMPLETE DRUG/ALCOHOL ASSESSMENT. COMMENTS: _______________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________________________________________________________________________________ _____________________________________________ _____________________________________________

Source: http://rcdmh.org/opencms/english/mental_plan/2010_Outpatient_Attachments/Attachment_11A_Adult_Medical_Historyx_English.pdf

fittings.it

PLASTIC LITHIUM CELL HOLDERS “1/2AA” • “CR2” • “2/3A” FEATURES APPLICATIONS • Snap-In PC contact holds in position for wave soldering • Computer memory, power transfer and back-up systems • Tin Nickel Plated contacts for excellent solderability and durability • Video and telecommunications power back-up requirements • Polarity cle

cosmeticsurgeon.org.nz

POST OPERATIVE INSTRUCTIONS CARPAL TUNNEL SURGERY Carpal tunnel syndrome is a disorder of the hand which can result in characteristic symptoms of waking at night with pain and tingling (usually the thumb, index and middle fingers), loss of feeling in the hand, clumsiness and difficulty with manual Description of Carpal Tunnel Syndrome The carpal tunnel is a narrow tunnel formed by

© 2010-2017 Pharmacy Pills Pdf