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Medication history

RDCRN#: 5202
Medication History Form
Growth Hormone:
Is your child currently on growth hormone? O Yes O No If applicable, what type of growth hormone? If not currently, has your child ever been on growth hormone in the past? O Yes O No If applicable, how old was your child when he/she started growth hormone? ________ years If applicable, how old was your child when he/she stopped growth hormone? ________ years If growth hormone was stopped, why was it discontinued? (Indicate all that apply) □ Side effects (describe) __________________________________ □ Due to age/ had stopped growing □ Child’s decision □ Behavioral problems □ Insurance would not pay □ Research study completed □ Other (describe) _____________________ Sex Hormones:
Males Only:
Is your child currently on testosterone? O Yes O No If not on currently, has your child ever been on testosterone in the past? O Yes O No If applicable, how old was your child when he started testosterone? _________ years RDCRN#: 5202
Medication History Form
If applicable, how old was your child when he stopped testosterone? _________ years What type of administration of the testosterone? (check box) If testosterone was stopped, why was it discontinued? (Indicate all that apply) □ Other side effects (describe) _________________________________ □ Other (describe)____________________________________________ Females Only:
Is your child currently on estrogen? O Yes O No If not on currently, has your child ever been on estrogen in the past? O Yes O No If applicable, how old was your child when she started estrogen? __________ years If applicable, how old was your child when she stopped estrogen? _________ yea7rs □ Oral contraceptives (type): Dose___________ O Monophasic-Alesse RDCRN#: 5202
Medication History Form
□ Premarin/provera: Dose ______mg per day □ Premarin only: Dose ______mg per day □ Depo-provera: Dose _______ mg/ml □ Progesterone only: Dose______ mg □ Other (please list name and dose) __________________________ If estrogen was stopped, why was it discontinued? Other side effects (describe) _______________________________________ Other (describe) _________________________________________________ Psychotropic medications:
Is your child currently on or have they ever been on any of the following medications? (indicate all that apply – leave dose blank if you do not know) SSRI’s
Prozac(fluoxetine) O Yes O No Dose ___________ from _____ to _____ O Ongoing Zoloft (sertraline) O Yes O No Dose ___________ from _____ to _____ O Ongoing Paxil (paroxetine) O Yes O No Dose ___________ from _____ to _____ O Ongoing RDCRN#: 5202
Medication History Form
Other: please specify__________________ O Yes O No Dose ___________ from _____ to _____ O Ongoing Antidepressants
O Yes O No Dose ___________ from _____ to _____ O Ongoing O Yes O No Dose ___________ from _____ to _____ O Ongoing Other: please specify __________________ O Yes O No Dose ___________ from _____ to _____ O Ongoing Antiepileptics
O Yes O No Dose ___________ from _____ to _____ O Ongoing Tegretol (carbamazepine) O Yes O No Dose ___________ from _____ to _____ O Ongoing O Yes O No Dose ___________ from _____ to _____ O Ongoing O Yes O No Dose ___________ from _____ to _____ O Ongoing Stimulants
Provigil (modafanil) O Yes O No Dose ___________ from _____ to _____ O Ongoing Ritalin (methylphenidate) O Yes O No Dose ___________ from _____ to _____ O Ongoing O Yes O No Dose ___________ from _____ to _____ O Ongoing Antipsychotics
Risperdal (risperidone) O Yes O No Dose ___________ from _____ to _____ O Ongoing Seroquel (quetiapine) O Yes O No Dose __________ from _____ to _____ O Ongoing O Yes O No Dose ___________ from _____ to _____ O Ongoing Haldol (haloperidol) O Yes O No Dose ___________ from _____ to _____ O Ongoing O Yes O No Dose ___________ from _____ to _____ O Ongoing How would you rate the effectiveness of the psychotropic medication(s) your child is currently on?  not effective  somewhat effective  effective  very effective Do you have any comments on past psychotropic medications your child has been on? ________________________________________________________________________________________________________________________________________________________________ RDCRN#: 5202
Medication History Form
Is your child currently on or have they ever been on any of the following medications? (indicate all that apply – leave dose blank if you do not know) O Yes O No Dose ___________ from _____ to _____ O Ongoing O Yes O No Dose ___________ from _____ to _____ O Ongoing O Yes O No Dose ___________ from _____ to _____ O Ongoing O Yes O No Dose ___________ from _____ to _____ O Ongoing O Yes O No Dose ___________ from _____ to _____ O Ongoing Saliva stimulants (e.g.biotene) O Yes O No Dose ___________from _____ to _____ O Ongoing DDAVP (desmopressin) O Yes O No Dose ___________ from _____ to _____ O Ongoing Metformin (glucophage) O Yes O No Dose ___________ from _____ to _____ O Ongoing O Yes O No Dose ___________ from _____ to _____ O Ongoing Dose ___________ from _____ to _____ O Ongoing Other diabetes medication O Yes O No Dose ___________ from _____ to _____ O Ongoing O Yes O No Dose ___________ from _____ to _____ O Ongoing O Yes O No Dose ___________from _____ to ____ O Ongoing Other asthma medication O Yes O No Dose _________ from _____ to _____ O Ongoing O Yes O No Dose ___________ from _____ to _____ O Ongoing Multivitamin O Yes O No Dose ___________ from _____ to _____ O Ongoing RDCRN#: 5202
Medication History Form
O Yes O No Dose ___________ from _____ to _____ O Ongoing O Yes O No Dose ___________ from _____ to _____ O Ongoing O Yes O No Dose ___________ from _____ to _____ O Ongoing

Source: http://www.mammag.uci.edu/kimonis/docs/03032008_937_5202_Medication_History_17-Dec-07.pdf

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Stephen G. Boyce, MD, FACS K. Robert Wil iams, MD CONSULTATION APPOINTMENT Please make these preparations for your 1st appointment with your surgeon. 1. Complete steps 1-3 on the Coversheet Checklist 2. We will need to perform some tests to evaluate and prepare you for surgery. The cost of these is in addition to your consultation. Do not take any Antibiotic, Pepto-Bismol or Proton Pump

Atrial fibrillation

My AF journey My journey began when I reached menopause. It started slowly with palpations that lasted over a couple of days for a couple of hours at any one time. The pounding in my chest started to annoy me so I presented to the emergency department to find out what it was. The diagnosis was atrial fibrillation (AF) and I was informed that I needed a cardiologist to investigate the cause.

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