allergic asthma. allergic alveolitis. f�N0+Y�YŤ�5�&��2Xf-�Ac혒:0����—�قi����w�Y�,�Q�����]w:���94UC�Ӂ�xZ�I�h�n8��a�(�v�i�vjh���jU��)�U��]���j������'��c.�֭A�S�~�{T�Әi*�u����^�� �s&���~98g���p�L�G��e+�t`{��E�B!y��C0L��v��Y�N~4L PATIENT NAME: DOB: REASON FOR VISIT: PROVIDER: MEDICAL HISTORY CONDITION Date Began Date Began Diabetes (Type _____) High Blood Pressure Cancer (Type_____) Stroke COPD High Cholesterol GERD Arthritis Gout Sleep Apnea Asthma Thyroid Disorder Allergic Rhinitis Other PREVIOUS SURGERIES / MAJOR INJURIES Type of surgery or injury Date PHARMACY Male Female Male Neutered Female Spayed . %%EOF Grade: _____ DOB: _____ Documented medical condition of student or household member: ____ Critical CONGENITAL (not congestive) heart disease Type: _____ ____ Organ transplant ____ Condition requiring active dialysis ____ Cancer requiring active chemotherapy endstream endobj 20 0 obj <>>> endobj 21 0 obj <>/Font<>/ProcSet[/PDF/Text]>>/Rotate 0/Tabs/S/TrimBox[8.64 8.64 620.64 800.64]/Type/Page>> endobj 22 0 obj <>stream Medical » Hospitals. h�b```f``�a`e`�bd@ A�(� ��7@ �?�%N����2:FI���!���� �@���X�a\�f$�%���!���a� �����4�1mc��^ 2�@��@7�:��^QƠ �/� ��_�ĝ@�������h` �E*� %PDF-1.5 %���� !x/��J:~2�&k�r�GG�]y`]`Z�����0"f�I5��6{���/.�y��?O/��dd����0k�UjF?�E��W��� � �~Sͦ���d����&��f�>}R�V�eS���'��:PMI�����k��j�V��d�?Fa��f�_��tݬ6{���6�����r��T7�B��i�w^-���ݴ~ Ne��m(|����$!~S��FU�ʇ�]�b����v*e4��ZG� "@$��2��L`�� Patient Full Name: DOB: Medical Condition: ICD-10: CPT/HCPCS Code: B4160 To Whom It May Concern:, age years, height (cm) , weight (kg) , is followed by at the , for , ICD-10: . Dog Cat . He has intermittent right hand pain that is described as throbbing, aggravated by grasping and lifting. h�bbd```b``� *���xl� h�ݡ?\���]�h��qKp�{�k�H��{72�(7 • The medical summary focuses on Motor vehicle collision on MM/DD/YYYY, the injuries and clinical condition of XXXX as a result of accident, treatments rendered for the complaints and progress of the condition. 39 0 obj <>/Filter/FlateDecode/ID[]/Index[19 39]/Info 18 0 R/Length 97/Prev 448378/Root 20 0 R/Size 58/Type/XRef/W[1 3 1]>>stream Is aware of environmental risks (increased elevation for sickle cell, large crowds if immunosuppressed). Please disclose to us any condition that compromises your immune system and understand that we may ask you to consider rescheduling treatment after discussing any such conditions with us. Miscellaneous » Names and Nicknames. endstream endobj startxref 3. �2�jm2� ��H����[�|@�*����~I"b���Rc,�3�|4�R�&��]q1�*�h��Je�і���H�������4�sq�88�לN%�wd1���Z���1Oi��� U�ֳ�����,�fA������vqUͰ�C��OC���,���Y�hT��,��g��x�V��?�zlF��.1:G�����X�`������� T�GP��! CHIEF COMPLAINT (Please describe the medical condition which brings you here today) CURRENT MEDICATIONS DOSAGE FREQUENCY REASON (Please include any over-the-counter medications, vitamins, and holistic treatments.) radiation, chemotherapy, and any prior or current disease or medical condition), can put you at greater risk for contracting COVID-19. Recovering from a chronic or acute medical condition & requires significant assistance with ADLs; Medical conditions requiring Home Health visits or frequent staff observation (IV antibiotics, O2, Incontinence, catheter care, colostomy care, dialysis) Tier 4: … Rep.) ( ) (7) Site Telephone Number ( ) ( ) Must check one: Participant is disabled or has a medical condition and requires a special meal or accommodation. (circle one) YES NO If YES please choose the appropriate medical condition(s) from the area below: Allergy-Life Threatening: Food Hearing Impairment Specify: Hearing Aid Deaf Preferential Seating Medication: (2) Age or DOB (3) Sponsor (4) Site (5) Name of Parent , Guardian, or Auth. Rep. (6) Telephone (Parent , Guardian, or Auth. • Initial and final therapy evaluation has been summarized in detail. endstream endobj startxref ACUTE MYOCARDIAL INFARCTION ADMIssION ORDER Name: _____ Age: _____ DOB: _____ /_____ / _____ Medical record #: _____ 0 H�\��j�0@�� Diagnosis: _____ 2. I understand that the Secretary of State may disclose such relevant medical information as is necessary to the investigation Is aware of foods/other environmental triggers to avoid in public places (food Pain is aggravated by walking, bending, sitting, and lifting. The following procedures are developed in consultation with the parent/guardian and implemented to help protect the child diagnosed at risk. acute lung injury. DOB: Débat d'Orientation Budgétaire (French: Budget Orientation Debate) DOB: Difficulty of Breathing (medical condition) DOB: Dying of Boredom: DOB: Damenoberbekleidung (German retail women's clothing) DOB: Digital Object: DOB: Data Object: DOB: Dogs of Battle (gaming clan) DOB: Division of Banks: DOB: Do Our Best (Cub Scouts of Canada) DOB Rate it: DOB: Dylan O'Brien. Yes No . ̖�l`�6��&��ɋ`���� 26�.�\-`�X���1H2m ��A��=��$�O�]�,��He�?��O �f Rate it: DOB: Dawn Of Blood. Patient #3 Species . PATIENT NAME: _____ DOB: _____ I. K��~9ό��y�X1`�8� We will discuss your medical condition with person(s) you designate. (Refer to definition on reverse IF YES, WHOM? Computing » Gaming. Temp: _____ HR: _____ Resp: _____ BP: _____ FHT: _____ Reason for Transfer . Previous or existing medical condition . :E������$�W�31� �[�a�[}pk��,"U�>/J��iM�e�#ׅ�)>��\��bt�*�"\҆���͎d|�����#6���c�q����X��]���ςf�C\Ʋ��뤻��m!�?�E�_=D��@/�_���ߗ ʪ���'�/�߀��RS���� DO YOU WANT TO DESIGNATE A FAMILY MEMBER OR OTHER INDIVIDUAL WITH WHOM THE PROVIDER MAY DISCUSS YOUR MEDICAL CONDITION? 1. Monitoring of Health Condition Is able to verbalize indications for seeking medical care. �fu�G��*0�1~zQ�U�o�vsy���{28;��+�#�B���K�XZ��Ir]:��Uf�{L*�I��"0,Y��� ����$ x oF$��OT�Ԍn �;�H��1�kz�>���OY����q����� h��VmO�8�+����v� Vital Signs at Time of Transfer: Time: _____ : ____ am pm. Breed . DOB or approximate age - - Date . Participant’s name: DOB: Medical condition(s) indicating need for prescribed product: ICD Code: Duration of prescription (limited to 12 months): B. Formula/Product and WIC Supplemental Foods Formula/product prescribed: Amount prescribed per day: Special instructions for preparation or dilution: Supplemental foods: I understand that the Secretary of State may disclose such relevant medical information as is necessary to the investigation
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