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: _____________________________________

Please indicate date (month and year) of last immunization.
Tetanus Booster ____________
Patient Name: ____________________________________ Date: __________________

Current Medical Problems

Please “X” YES or NO
___ ___ Breast Disease
___ ___ Other, if any please explain: ________________________________________
Review of Systems

Please “X” YES or NO

Previous Hospitalizations

______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ Patient Name: ____________________________________ Date: __________________
Past Surgical History


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 _________


Impact of a uniform formulary on military health system prescribers: baseline survey results

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

Dual antiplatelet therapy after drug-eluting stent implantation ⁎editorials published in the journal of the american college of cardiology reflect the views of the authors and do not necessarily represent the views of jacc or the american college of cardiology.

Journal of the American College of Cardiology© 2012 by the American College of Cardiology Foundation 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

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