Surgery.med.sc.edu
Medical Information Database
Name: __________________________________________ Date: __________________
Reason for seeing doctor: ___________________________________________________
Referring Physician: _______________________________________________________
Were you seen in the Emergency Room? YES NO
___ Richland ___ Baptist ___ Lexington ___ Providence ___ Providence NE
___ Other
Date of accident or injury: _______________
If not accident or injury, date the symptoms began: __________________
Current physician, pediatrician, or family doctor, if you have one: __________________
Previous Medical History
List all known allergies: ____________________________________________________
________________________________________________________________________
Do you have a Latex Allergy/Sensitivity? YES NO
List all medications you are taking and reason you are taking it (including Aspirin,
Ibuprofen, Motrin, NSAID, Goody Powder, Vitamins, herbal Medication, etc.): _______
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
List any medications that you cannot take: _____________________________________
_______________________________________________________________________
Immunizations
Please indicate date (month and year) of last immunization.
Tetanus Booster ____________
Patient Name: ____________________________________ Date: __________________
Current Medical Problems
Please “X” YES or NO
YES NO
___ ___ Breast Disease
___ ___ Other, if any please explain: ________________________________________
Review of Systems
Please “X” YES or NO
YES NO
Previous Hospitalizations
Date
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
Patient Name: ____________________________________ Date: __________________
Past Surgical History
Date
Social History
Do you use tobacco products of any kind? YES / NO Amount / Frequency: __________
Do you drink alcohol? YES / NO Amount / Frequency: __________________________
Do you use illegal drugs? YES / NO Amount / Frequency: _______________________
Occupation: _____________________________________________________________
Living Situation: _________________________________________________________
Family History
Please “X” YES or NO and relationship
YES NO Relationship
Reviewed and updated on _____________ By _________
Reviewed and updated on _____________ By _________
Source: http://surgery.med.sc.edu/patientcare/forms/Plastic%20Surgery%20Medical%20Information%20Database.pdf
E. Comments from Survey Respondents In this appendix, we provide selected comments that we received from surveyrespondents. The comments have been organized according to the topicsdiscussed in Chapter 5 and are divided into three sections—general commentsfrom direct-care system prescribers; comments from direct-care prescribersspecifically in response to a question on changes they would make
Journal of the American College of Cardiology© 2012 by the American College of Cardiology Foundationhttp://dx.doi.org/10.1016/j.jacc.2012.08.003consistent lower rate of late or very late ST A recentnetwork meta-analysis presented the provocative findingthat within 2 years, EES might have a lower risk of ST thanBMS which, unlike common perception, might bebased on the possibility that polymer