Patient’s Name: ___________________________________________________ Date of Birth
Have you been diagnosed and/or treated for any of these conditions?
(Please Check All
_______Irregular Heart Beat (arrhythmia)
_______Kidney Disease requiring Dialysis
______Inflammatory Bowel Disease (Crohn’s Disease or Ulcerative Colitis
Cancer, please specify:________________________________
Skin Cancer BCC___________________________________SCC_____________________________________________ Melanoma site____________________when diagnosed_____________________ treatment______________________ Have you received a Blood Transfusion? Y or N Have you received X-ray Treatments for Acne? Y or N Have you received Light Treatment for any Kind of Skin Condition? Y or N Have you received Radiation Treatment for a Cancer? Y or N
(Please check All
Require Antibiotics Prior to Dental Procedures?
Develop Rashes / Reactions to Bandages / Tapes / Antibiotic Ointments?
Do you have any other medical conditions not previously mentioned? If yes, please list:
Please list all major SURGERIES
Females Only: (
if the patient has not undergone changes of puberty, circle n/a)
Do you develop frequent yeast infections when taking antibiotics? Y or N
Have you had your uterus removed (hysterectomy)? Y or N
Have you had your ovaries removed? Y or N
Have you had one or more miscarriages? Y or N
Y or N If so, when was last menstrual period? ___________
Do you have any Medication Al ergies? Y or N If yes, please list: __________________________________________________________
Other Al ergies? Seasonal/foods/environmental? _________________________________ _______________________________________
Please list all
medications you are currently taking (prescriptions, over-the-counter meds, vitamins & herbal supplements):
Patient’s Name: ______________________________________________
P. 2 Med Hx
Do you ever take aspirin, ibuprofen (Motrin, Advil) naproxen sodium (Al eve, Naprosyn), vitamin E supplements, garlic,
ginger, gingko or ginseng supplements? If yes, please list the items you do take and describe how often.
Have you ever had a reaction to local or general anesthesia? Y / N
Have you ever had a reaction to Epinephrine?
Do you have any family members (father, mother siblings or child) with the fol owing conditions?
(Please check ALL
____ Skin Condition (Please List)________________________
Are there any other diseases / conditions which run in your family? If yes, please list:_______________________________
Married / Separated / Divorced / Partnered
Do you use tobacco products of any kind? Y or N
If yes, list type_____________________ Amount per day___________________
If yes, how much? (# of drinks per day, week, or month)________________________
Do you or have you ever used recreational drugs? Y or N
If yes, what? _______________________ Route taken? (Oral, IV, nasal, smoke)
Have you ever been exposed to HIV? Y or N
What is your occupation?_______________________________________________________
Review of Systems:
Are you experiencing any of the fol owing symptoms currently or in the last 6
(Please check ALL that apply
Digitally signed by Skin Solutions Dermatology
DN: cn=Skin Solutions Dermatology, o=Skin Solutions
When exposed to the sun in the spring (first significant sun exposure of the warm season), do you
(Please check ONE
_____ Sometimes Burns, Always Tans (I I)
Patient Signature __________________________________ Date / / Reviewed & Updated / / Initial . Legal Representative__________________________________ Date / / Reviewed & Updated / / Initial .
Physician’s Signature Date / / Update Reviewed / / Initial .
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Cimzia® (certolizumab pegol) COVERAGE CRITERIA DRUG CLASS: GI Drugs, Miscellaneous – AHFS 56:92 BRAND NAME: Cimzia® GENERIC NAME: certolizumab pegol POLICY #: 0261 CATEGORY: Commercial FDA INDICATIONS : • Crohn’s Disease (CD) – for reducing signs and symptoms of Crohn’s disease and maintaining clinical response in adult patients with moderately to severely a
The New WBF IMP to VP Scales Technical Report of WBF Scoring Panel Technical Panel : Max Bavin, Henry Bethe, Bart Bramley, Peter Introduction This documents presents the theory and algorithms for producing the newWBF conversion tables from:The continuous scale gives a unique Victory Point (VP) to two decimalplaces for each integer IMP margin. The discrete scale, similar to existingWBF s