ࡱ> ?A> bjbj 4(ee68H,t+.kkk%+'+'+'+'+'+'+$-/K+EkkkkkK++kR%+k%+')E6,}v(++0+(R03jR0()R0)TkkkkkkkK+K+ kkk+kkkkR0kkkkkkkkk : Patient Information Update Name_________________________ ID Number_____________________ 1) Since your last visit to our office, were you admitted to the hospital? Yes j No j If yes, please write where and when:_____________________________________________ 2) Since your last visit to our office, have you had any medical tests? Yes j No j If yes, please check any that apply: j Mammogram (breast xray) j Pap smear (for women) j Colonoscopy j Blood work j X-rays j ECG / EKG (heart) j Vision j DEXA (checks for bone loss, or osteoporosis) j MRI j CT ( CAT scan) j other ______________ List where and when you had the tests done_____________________________________ 3) Since your last visit to our office, have you developed any new allergies or had a bad reaction to a medication or food? Yes j No j If yes, describe: _____________________________________________________________ 4) Since your last visit to our office, h(4NTVZ`ln    H `    h p ɾɷŰɾѫ|th9hp.5h'@hp. hsh'@ hshC hFhp.hFhp.5 hC5 hp.5 hp5 hp.huO hp.hx) hp.h|shkhphMh|sh5CJaJhuO5CJaJhkh)25hkhuO5hkh5*   d f h  ` l R gd|sgd%7*gdp.$a$gd|s $^a$gdx)gd  ` f   & * . 2 j l r ~ R T Z h z .Ft*HT\׽׽򗟗籓hJhFhp.5 hC5 hJ5hJhp.5hJhJ5h%7* *h'nh/ hMhp.hC hShp. *h'nhp. *h'nhC hFhp.hp. hp.5hqhp.5:20246np FHJbŽŶŏŏ}x}q hFh h-5 h5hh5 hs5h[Jh h=5hJh|s5 hFhq hFh|shp.hp.5 hJhqhqh= h|shqh|s5 huO5 hF5Uh9hF5hFhF5 hC5hFhq5 hp.5*ave 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? 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PLP^P`LhH.h_?5%_#/BdAv=MFvJ                                             :ذ                  @ONk?u9-,:ad (`(x)%7*++p./R3H`:<#"<f1>B@MJ}&QffnfFg 2h[Jh'ns)vwpw71Z{t!YjC7I"pS'@C,{r9(=d90d_nGF=5CuOJq2QqM|s1&JY= q=)2JM@@P00 0 00UnknownG*Ax Times New Roman5Symbol3. *Cx Arial5. .[`)TahomaA$BCambria Math"qhʴf4g´F    !`243QHP)?|s2!xx Patient Update Paula Woodward Windows User(       Oh+'0 0< \ h t  Patient Update Paula Woodward Normal.dotmWindows User7Microsoft Office Word@@8jl@+N@/(,} ՜.+,0 hp|     Patient Update Title  !"#$%&'()*+,-/012345789:;<=@Root Entry FV6,}B1Tablez0WordDocument4(SummaryInformation(.DocumentSummaryInformation86CompObjr  F Microsoft Word 97-2003 Document MSWordDocWord.Document.89q