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:
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____________________________________________________________________________________________________________ 5. PAST
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____________________________________________________________________________________________________________ 6. OTHER
MEDICATIONS (Includes Prescription and Non-Prescriptive Drugs):
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CURRENT USE OF ALCOHOL AND/OR STREET DRUGS:
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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: _______________________________________________________________________________________________
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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
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