Into the pediatrician's practice M.I. Petrovskaya, T.V. Kulichenko Scientific Center of Children's Health, RAMS, Moscow Herbal Treatment of Inflammatory Diseases of the Upper Respiratory Tract This article is devoted to one of the most common manifestations of diseases of respiratory system and upper respiratory tract - coughing. While performing a protective function , the cough in
Have2020.com2013 Patient Medical History
Date of Birth: _____________________ Emergency Contact/Phone:________________________
Pharmacy:____________________________________ Family Physician: _________________________ Referring Doctor: _______________________________ Do you wear? Glasses Contact Lenses (What type?) _______________________ □ No Glasses or Contacts Ethnicity: Hispanic Preferred Language: English / Other _____________ Race: ________________________________
Medications: Please list below (or provide a list of) all medications & non-prescription drugs.
□ Currently taking NO medications_______________________________________________________________
Have you ever used Flomax or Avodart? Yes No Are you allergic to Latex: Yes No
List all known medical allergies: ____________________________________________________________
___________________________________________________________________ □ No Known Allergies
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History: Have you been diagnosed with any of the following in the past?
□ Other Eye Disease ________________________ Cataracts. Cataract Surgery? Date: Right_________ Left___________ By: _________________ Laser treatments to your eyes? Date: Right_________ Left___________ By: _________________ Retina Surgery? Date: Right_________ Left___________ By: _________________ Have you had any eye surgeries (including laser treatments)? If so, give reason _______________________________________________________________ Patient Medical History: Have you been diagnosed with any of the following in the past?
Heart Disease/Carotid Artery Disease □ □ Autoimmune Disease (Type)____________________ □ □ Diabetes (Type I or II)_______# of years __________ □ Cancer (Type)_______________________________ Any other disease ______________ □ □ Permanent Defect from Illness or injury__________ For female patients, are you currently pregnant or nursing? Yes No Surgical History: (Please Include Date and Type)________________________________________________
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□ Retinal Detachment ______________________ Diabetes (IDDM/Type 2) ___________________ Diabetic Retinopathy ______________________ Corneal Disease ________________ □ □ High Blood Pressure ______________________ Heart Disease ___________________________ Retinitis Pigmentosa ____________ □ □ Other General Health Problems _______________
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□ Blurred Vision □ Double Vision □ Contact Lens Problem □ Problems in school □ Redness □ Dry Eye □ Burning □ Itching □ Watering □ Irritation □ Injury □ Pain □ Light Sensitivity □ Flashes □ Floaters Optical Complaints: (Check all that apply)
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Happy with contacts? □ YES □ NO Please explain:_______________________________________________________
Review of Systems: Do you currently have any of the following symptoms?
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□ □ Heat Intolerance
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