ࡱ> HJG 1bjbj 4:   YYYmmmm<$mr,.+++++++-B0+]Y+  ,,OOO 8Y+O+OO(AW*в(Hmd3)+B,0r,G)060(W*0Ye*T"O++9r,0 : Patient Information Update Name_________________________ ID Number_____________________ 1) Since your last visit to our office, were you admitted to the hospital? Yes j No j If yes, please write where and when:____________________________________________ 2) Since your last visit to our office, have you had any medical tests? Yes j No j If yes, please check any that apply: j Mammogram (breast xray) j Pap smear (for women) j Colonoscopy j Blood work j X-rays j ECG / EKG (heart) j Vision j DEXA (checks for bone loss, or osteoporosis) j MRI j CT ( CAT scan) j other ______________ List where and when you had the tests done_____________________________________ 3) Since your last visit to our office, have you developed any new allergies or had a bad reaction to a medication or food? Yes j No j If yes, describe: _____________________________________________________________ 4) Since your last visit to our office, have you seen a specialist (such as a doctor for diabetes, heart, kidneys, cancer, eyes, gynecology, etc.)? Yes j No j If yes, who did you see and when? Name Approx. Date Name Approx. Date 5) Since your last visit to our office, have you had any vaccinations (shots)? Yes j No j If yes, check the shots you received: j flu j tetanus j pneumonia j other - please list:__________________________________________________________ 6) Since your last visit to our office, have you started any new prescribed medications? Yes j No j If yes, list: _________________________________________________________________ ___________________________________________________________________________ (please turn over) Patient Update pg (4NTVZb   < T  Z b žž̾žԳ}umhqhp.5h9hp.5h'@hp.hZvh'@5hZvhC5 hFhp.hFhp.5 hC5 hp.5 hp5hY hp.huO hp.hx) hp.h|shphMh|sh|shuO5CJaJh)25CJaJhuO5CJaJh5CJaJ*   V X Z  R ^ D gd%7*gdp.gd|s$a$gd|s $^a$gdx)gd  R X ~    $ \ ^ d p t  D F L Z l  8f:FN󾶮󩟗춓hJhFhp.5 hp.5 hC5 hJ5hJhp.5hJhJ5h%7* *h.h/ hMhp.hC hShp. *h.hp. *h.hC hFhp.hp.hqhp.59$"$&(`b8:<Td̖̖̽Ȓ{tlh=h5 hFh h-5 h5hh5 hp.5hZvh[Jh h=5hJh|s5 hFhq hFh|shp.hp.5 hJhqhqh= h|shqh|s5 huO5 hF5h9hF5hFhF5 hC5hFhq5($&^`<T<Tgdp.$a$gdp.gd1&gdYgd= gd &d P gd|sgd|sdv|~8:<Tlftz½~z~~~v~vv~khMh#"<CJaJh1&hJhYhZvhY5 hFhY h#"<5h= h= 5 huO5 hF5h9hF5hFhF5 hC5 hY5hYhY5 hp.5hMhnf5CJaJhqhZvhp.h= hh=h5h=h=5&$$$$ $ $$B$n$$ %%"%&%J%%%&&&4':'D'F'''((((ƽwwpph``YpY hh (hh (5hhp.5 hhp.hh5 hh hhnG hh#"<hhF5hhC5hh#"<5hhM5hp5CJaJh=5CJaJhMhp.5CJaJUhMhp.CJaJh=CJaJhMh#"<5CJaJhYhp.5CJaJ"2 7) Since your last visit to our office, have you started any new over-the-counter medications (such as Advil, Tylenol, aspirin, Tums, etc.), herbal medications (such as St. John s Wort, etc.), vitamins or minerals (such as Vitamin C, or Calcium, etc.)? Yes j No j If yes, please list: ____________________________________________________________ _______________________________________________________________ 8) Has anything changed with the health of your family members (including parents, siblings, or children)? Yes j No j If yes, please list: ____________________________________________________________ 9) Do you regularly use: Seat belts Sometimes j Always j N/A j Car seats for children in your car Sometimes j Always j N/A j 10) Do you have a working smoke alarm in your home and have you changed the batteries within the past 6 months? Yes j No j 11) Do you exercise at least 20-30 minutes 3 times per week? Yes j No j 12) Do you find it difficult keeping your balance or have you fallen recently? Yes j No j 13) Do you sometimes have difficulty getting to the restroom  in time, and/or do you sometimes have urinary accidents when sneezing or coughing? Yes j No j 14) Do you feel sad,  down, depressed or hopeless? Yes j No j 15a) If you smoke or chew tobacco, have you thought about quitting? Yes j No j 15b) If you ve thought about quitting, would you like help to do so? Yes j No j 16) Has anyone been concerned about your drinking of alcohol or use of drugs? Yes j No j 17) Do you have a gun in the home? Yes j No j 18) Have you had sex with more than one partner within the past year? 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PLP^P`LhH.h_?5%_#/BdAv=MFvJ                                             :ذ                  @ON?u9-,:Zv.ad (`(x)%7*++p./R3H`:<#"<f1>B@$JMJ}&Qffnf 2h[JhiNo. q)vwpw71Z{t!YjC7I"pS'@C,{r9(=d90d_nGF=uOJqQqM|s1&JY= XFq=)2JM @X  $UnknownG* Times New Roman5Symbol3. * Arial5. *aTahomaA BCambria Math"h9*$zf´F'  !`24d 2QHP)?|s2!xxPatient Update Paula WoodwardPaula Woodward(       Oh+'0 ,8 X d p | Patient Update Paula WoodwardNormalPaula Woodward39Microsoft Office Word@ $@8jl@3w@8H ՜.+,0 hp|     Patient Update Title  !"#$%&'()*+,-./012345689:;<=>@ABCDEFIRoot Entry F(2HK1Table 1WordDocument4:SummaryInformation(7DocumentSummaryInformation8?CompObjy  F'Microsoft Office Word 97-2003 Document MSWordDocWord.Document.89q