Mais les résultats doivent être attendus longtemps et il n'y a généralement pas de temps metronidazole prix L'autre cas, c'est que l'achat d'un ou d'un autre antibiotique dans une pharmacie classique nécessite des dépenses matérielles considérables et pas toutes les personnes ne peuvent acheter des produits pharmaceutiques aussi coûteux.

Last name:_________________________

Confidential Health History Questionnaire
Full Name: ___________________________________________ Initial Visit Date: __________ (Circle): single partner living together married divorced widow Miss Ms. Mrs. Mr. Date of Birth: _______/_______/_______ Age: _______ SSN: _______-_______-______ Home Address: _________________________________________________________________ Home phone: ( ) Occupation: ____________________________ Employer: ______________________________ Email Address: _________________________________________________________________ How did you hear about our office? (circle) Friend Patient Name:_____________________ Physician referral Name:__________________ Website Internet Newspaper Emergency contact: _____________________ phone #: ________________________________
Primary Care Physician: ______________________________ phone #:___________________
OBGYN: ___________________________________________ phone #:___________________
Primary Insurance Carrier: __________________________ ID#:______________________
Name on card: _________________________ relationship to patient: ______________________
Secondary Insurance Carrier: _________________________ ID#:______________________
Name on card: _________________________ relationship to patient: ______________________ LIST AREAS OF PAIN AND OTHER CONDITIONS TO BE TREATED:
1. ____________________________________________________________________________
How long have you had this: _______ days/weeks/months/years? Is this a flare up? Yes/No How frequently do you experience this condition: constant/daily/monthly/seasonally What is the Intensity of your Discomfort: 1 – 10 (10 being most severe): _____
Is your pain or discomfort:
( ) Sharp ( ) Burning ( ) Aching ( ) Cramping ( ) Tight
Have you had an ( ) X-ray ( ) MRI ( ) CAT scan ( )other: ______________________ Treating Physicians (circle): MD PT ORTHO CHIRO other:_____________________

2.
____________________________________________________________________________
How long have you had this: _______ days/weeks/months/years. Is this a flare up? Yes/No How frequently do you experience this condition: constant/daily/monthly/seasonally What is the Intensity of your Discomfort: 1 – 10 (10 being most severe): _____
Is your pain or discomfort:
( ) Sharp ( ) Burning ( ) Aching ( ) Cramping ( ) Tight
Have you had an ( ) X-ray ( ) MRI ( ) CAT scan ( )other: ______________________
Treating Physicians (circle): MD PT ORTHO CHIRO other:_____________________
Are any of the above conditions due to an automobile accident? YES/NO

Is there an active personal injury case? YES/NO
Ocean Acupuncture & Herbal Medicine, LLC 102 East Bay Avenue, Suite C, Manahawkin, NJ 08050 phone: (609) 978-1428 fax: (609) 978-1610 Confidential Health History Questionnaire
Pain Management: CHECK ALL areas where you experience pain and discomfort:

HEAD ( ) temples ( ) forehead ( ) sinuses
( ) low back ( ) abdomen ( ) intestines ( ) hips
Medical History:

Month and year of your last Physical: _____/_____ Bloodwork: _____/_____
Month and year of your last Colonoscopy: _____/_____ ____ Have not had one

CHECK any condition YOU have had or currently have.

( ) Addiction: ___________ ( ) Ebstein Barr Virus, EBV ( ) Meningitis, viral/bacterial
( ) Allergies
( ) Headaches: tension / cluster ( ) Osteoporosis ( ) Bursitis: _____________ ( ) Heart Disease: heart attack ( ) Pneumonia ( ) Cancer: _____________ ( ) Hepatitis A/B/C, chronic ( ) Polio ( ) Cancer: _____________ ( ) High Blood Pressure ( ) High Cholesterol: _____ ( ) Reflux / Ulcers FAMILY HISTORY: Check if your family members have had the conditions below:
Heart Attack/Stroke Cancer High Blood Pressure High Cholesterol Depression _____________________________________________________________________________________________________________________________ ___________________________________________________________________________________________
Please list ALL known ALLERGIES:

1. ________________________________________
2. ________________________________________ Ocean Acupuncture & Herbal Medicine, LLC 102 East Bay Avenue, Suite C, Manahawkin, NJ 08050 phone: (609) 978-1428 fax: (609) 978-1610 Confidential Health History Questionnaire
Medications & Supplements Dosage
What Condition _ How Long
2. __________________________ __________ 3. __________________________ __________ 4. __________________________ __________
Use back of paper if you need extra room. ____ See back of paper (check if needed)

Please list your surgeries and/or hospitalizations Year
For what condition___
1.________________________________________ 2. _______________________________________ 3. _______________________________________ 4. _______________________________________ WOMEN ONLY: MENSTRUAL AND FERTILITY INFORMATION:

Age of first menstruation: _________________
Days of Cycle (period to period): # ________ Average number of days you bleed: _________ Pregnancies: _____ Miscarriages: _____ Fertility specialist:_______________________ CHECK if you have or had any of these conditions?
( ) pain between cycles ( ) endometriosis ( ) yeast infections ( ) fibrocystic breasts ( ) ovarian cysts ( ) spotting between cycles ( ) hysterectomy: partial or full ( ) Menopausal changes Mark a “B” if symptom occurs Before your cycle begins, “D” if during, and “A” if after.
( ) breast tenderness ( ) heavy bleeding ( ) clots: small/large ( ) abdominal pain
MEN ONLY: Please check if you have any of the following conditions:

( ) Low testosterone ( ) Erectile dysfunction ( ) STD
BRING IN ALL TESTS, REPORTS AND BLOODWORK TO YOUR FIRST VISIT.
Patient/Guardian Signature: ___________________Print Name: ________________

Ocean Acupuncture & Herbal Medicine, LLC 102 East Bay Avenue, Suite C, Manahawkin, NJ 08050 phone: (609) 978-1428 fax: (609) 978-1610

Source: http://www.oceanacupuncture.net/Portals/18/Docs/ROF_D1_HEALTH_HX_QUESTIONAIRE.pdf

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FORÅRSCAFÉ Faaborg Gymnasium 24.april 2012 Billedkunst, Musik & Drama Til gymnasiets årlige forårscafé præsenterer de kunstneriske fag musik, billedkunst og drama deres eksamensprojekter. Der vil være noget for mange sanser - dejlige billeder, flot musik og spændende teater – og al kunsten vil kunne blive suppleret med noget godt at spise og drikke. Som det fremgår af prog

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CURRICULUM VITAE Name: Mr. Apichat Vitta Date of birth: 12-17-1978 Place of birth: Maha-Sarakham Province, Thailand Nationality: Thai Home address: 2/4, Nachuak-Porpan Road, Sub-district Nachuak, District Nachuak, Office Position: Department of Microbiology & Parasitology, Faculty of Medical Science, Naresuan University, Phitsanulok, Thailand 65000 Tel : +66 05

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