Plastische-wesseling.de
DREIFALTIGKEITS-KRANKENHAUS WESSELINGAbteilung für Plastische Chirurgie Chefarzt: Dr. med. Dirk F. Richter
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Name / Vorname:_____________________________________________________________
Straße: _____________________________________________________________________
PLZ: ____________ Ort: ______________________________________________________
Telefon (Privat) : ___________________________ (Mobil): ___________________________
Telefon tagsüber:___________________________
Email-Adresse: _______________________________________________________________
Beruf: _____________________________________________________________________
Hausarzt: Name: __________________________ Ort: ______________________________
Überweisende Arzt: Name: __________________
Empfohlen durch: _____________________________________________________________
Versicherung: ________________________________________________________________
Vorerkrankungen:
Medikamente:___________________________________
Medikamente:___________________________________
welche:________________________________________
Medikamente:___________________________________
welche:________________________________________
welche:________________________________________
welcher:_________________________________
welche:________________________________________
welche:__________________________________
welche:__________________________________
Medikamente:_____________________________
Allergien :
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Nehmen Sie regelmäßig Medikamente ein?
Plavix, Aspirin ( ASS): nein: € ja : €
Welche: __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Körpergröße ( in cm ): ______________ Gewicht ( in Kg. ): _________________
Ich trage Kontaktlinsen:
Operationen in letzten zehn Jahren:
Plastisch-Chirurgische Vorbehandlungen:
Botox oder Unterspritzungen: nein: € ja : €
wann zuletzt:______________________________
welche + wann:___________________________
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Seit wann beschäftigen Sie sich mit dem Thema?
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Source: http://www.plastische-wesseling.de/relaunch/wp-content/uploads/2009/01/anamneseboge.pdf
Risk assessment based on single dose of a 1:5 dried plant tincture (unless otherwise stated). A = 5ml, B = 2.5ml recommended single dose 0=no known risk 1=low risk 2=moderate risk 3=severe riskAconitum napellus (Monkshood) Schedule III - external only 1.3%Acorus calamus (Sweet Flag)Aesculus hippocastanum (Horse Chestnut)Agrimonia eupatoria (Agrimony)Agropyron repens (Couch Grass)Alchemilla arvens
Technical Procedure for ELISA Drug Screen ___________________________________________________________________________________________________ ELISA Drug Screen Purpose - This procedure specifies the required elements for the calibration and use of the Tecan Freedom EVO 75 Workstation for an ELISA Drug Screen. Scope – This procedure applies to the Toxicology Units of the State Crime
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DREIFALTIGKEITS-KRANKENHAUS WESSELINGAbteilung für Plastische Chirurgie Chefarzt: Dr. med. Dirk F. Richter
Anmelde- / Anamnesebogen