DONE! You can now close the browser.
|
|
|
- Adele Jacobs
- 6 years ago
- Views:
Transcription
1 Visit My Doctor Online at kp.org/mydoctor. Prepare for your visit This form will help you prepare for your upcoming visit with your doctor. You can complete it on your computer (Mac or PC) and it to your doctor ahead of time. Or, you may fill it out on the computer, print it, and bring it with you to your visit. Instructions for completing and saving this form vary depending on whether you use a Mac or a PC. To send us your feedback or questions about the form, please helpwithforms@kp.org. Caution: When using a public computer (library, Internet cafe, etc.), saving your entries may make it possible for others to view your information. To avoid this, never save your personal information on a public computer. How to fill out the form Step 1 PC users: Use your mouse to position your cursor over the field you would like to complete. Click inside the field and when your cursor appears, type your response to each question using your keyboard. Mac users: See Step 2. Step 2 Step 3 PC users: Please use your native browser (Internet Explorer): Click the Save button at the bottom of the form to create a copy of your completed form as a PDF document on your computer. In the dialog box that opens, select the folder where you want to store this file and click Save. Do not save the file under a new name. Remember where you save this file. To print the form, select the Print button at the bottom of the form. Mac users: Please use your native browser (Safari): From the File menu select Save as to create a copy of your uncompleted form as a PDF document on your computer. In the dialog box that opens, select the folder where you want to store this file and click Save. Do not save the file under a new name. Remember where you save this file. To fill out the form, open it with Acrobat Reader. Then, use your mouse to position your cursor over the field you would like to complete. Click inside the field and when your cursor appears, type your response to each question using your keyboard. Save your file under the same name. To print the form, select the Print dialog box from the File menu on Acrobat. PC users, when you are ready to send this form, click the Form button, which will launch your browser. Then log in to your kp.org account. Mac users, please launch your browser and login to your kp.org account. Once your login is successful, create a message to your doctor. Attach the completed form by clicking on Browse in the Attach File section below your message. In the dialog box that opens on your screen, locate the form you saved on your computer in Step 2. Click on the file name to select it and click Open. This will select the form to be attached to your message. Click Send to send the message to your doctor. DONE! You can now close the browser. 2012, TPMG, Inc. All rights reserved.
2 Member Health History Name Today s Date Medical Record No Place of birth Your Occupation Marital Status Your Partner s Occupation If you have children, what are their ages? Who lives with you or do you live alone? What are your hobbies? PERSONAL MEDICAL HISTORY Allergy [Enter Asthma COPD/Emphysema Atrial fibrillation Heart murmur as an adult Heart disease/heart attack Congestive heart failure Rheumatic fever High cholesterol High blood pressure History of cancer or tumor [Enter Thyroid condition (hypo or hyper) [Enter Diabetes Osteoporosis Bone fractures Radiation treatments to the head/neck [Enter Glaucoma Acid reflux or heartburn Hepatitis [Enter Liver Cirrhosis Stomach or duodenal ulcer Irritable bowel disease Colon or bowel disease (including polyps) [Enter 2012 Kaiser Permanente All Rights Reserved DRAFT FORM No. PC-1 XXX FORM Page 1 of 5
3 PERSONAL MEDICAL HISTORY (continued) Kidney problem (including stones) Gynecologic problems (including fibroids or endometriosis) Prostate problems Migraine headaches Stroke Seizures/Epilepsy Arthritis Rheumatoid Arthritis or Lupus Gout Anemia Blood clots Blood transfusion before 1992 History of chicken pox Spleen removed History of pneumonia History of positive skin test for tuberculosis Alcohol/drug problem Anxiety or panic attacks Depression Bipolar disease Vegetarian diet PERSONAL SURGICAL HISTORY Abdominal surgery Appendix removed Back surgery Biopsy Breast surgery Coronary bypass Coronary stenting Gallbladder removal Heart surgery (other than bypass/stents) Page 2 of 5
4 PERSONAL SURGICAL HISTORY (continued) Hip surgery Hysterectomy (ovaries removed) Hysterectomy (ovaries left) Knee surgery Neck surgery Tubal ligation Spleen removed Other MEDICATIONS NAME DOSE DIRECTIONS DRUG ALLERGIES DRUG NAME REACTION Page 3 of 5
5 FAMILY HISTORY (check all that apply) NONE MOTHER FATHER SISTER BROTHER GRANDMOTHER GRANDFATHER Healthy Heart Disease Diabetes Drug Addiction Hypertension Hyperlipidemia Stroke Colon Cancer Colon Polyp Breast Cancer Prostate Cancer Alzheimer Disease Osteoporosis Aortic Aneurysm Alcohol Problem Anxiety Bleeding Disorder Clotting Disorder Depression Genetic Disorder Hemochromatosis Hepatitis Ovarian Cancer Panic Disorder Tuberculosis Thyroid Cancer Thyroid Disorder Page 4 of 5
6 PREVENTATIVE CARE (indicate dates, please bring documentation with you to your visit) Pneumonia vaccine Colonoscopy Tetanus vaccine Pap smear Zoster or chickenpox vaccine Mammogram Bone density scan OTHER HEALTH ISSUES Tobacco use Never Current smoker? Packs/day # Years Former smoker? # Years smoked Quit Date Other tobacco, including pipes, cigars, snuff, or chews Alcohol use Type of drink # of drinks /week Drug use Do you use marijuana or recreational drugs? Have you ever used needles to inject drugs? Sexual Activity Are you sexually active? Do you have sex with: Men Women Both Birth control method Do you have an Advance Directive for Health Care (ADHC)? Do you have a Durable Power of Attorney for medical decision-making? Do you have a Physician Order for Life Sustaining Therapy (POLST)? Page 5 of 5
HEALTH HISTORY QUESTIONNAIRE
L 3/11 Page 1 HEALTH HISTORY QUESTIONNAIRE NAME: DATE: HOME ADDRESS: HOME PHONE: WORK PHONE: CELL PHONE: OTHER PHONE: EMPLOYER: OCCUPATION: EXPLAIN YOUR JOB DUTIES: DATE OF BIRTH: SEX: MALE /FEMALE SS#
Hematology Oncology Associate of Central New York Medical History
Hematology Oncology Associate of Central New York Medical History Name: Date: Male Female Age: Consult Date: Reason for today s visit: Referring Doctor: Primary Care Doctor: Surgeon & Other Doctors: Medical
NEW PATIENT HISTORY FORM. Name: Main Reasons for coming to the office: Duration of Problem (when did it first start?):
NEW PATIENT HISTORY FORM Main Reasons for coming to the office: Location of Problem(s): Please briefly describe the problem(s): How severe is your problem (please circle): Duration of Problem (when did
Please do not leave anything blank. If something does not apply please put N/A.
Name: _ Date of Birth Date Please describe the reason for your visit. Include Symptoms, duration, location, and severity: Select any of the following medical conditions that you currently have: Anxiety
Please print all information in the spaces provided. Be sure to complete and sign the statement on the bottom of this form. Last Name First Name M.I.
916-423-2124 916-423-2127 fax gastroconsultantsmedgrp.com Patient Information Form Thomas J. Imperato, M.D. John T. Hata, M.D. Rekha Cheruvattath, M.D. Please print all information in the spaces provided.
CLIENT HEALTH QUESTIONNAIRE AND INITIAL SCREENING QUESTIONS HEALTH QUESTIONNAIRE INSTRUCTIONS
CLIENT HEALTH QUESTIONNAIRE AND INITIAL SCREENING QUESTIONS HEALTH QUESTIONNAIRE INSTRUCTIONS If Incidental Medical Services (IMS) are to be provided, the Incidental Medical Services Certification Form
JON PEMBROKE KELLY, M.D., F.A.A.O.S. ORTHOPAEDIC SURGERY PATIENT QUESTIONNAIRE
JON PEMBROKE KELLY, M.D., F.A.A.O.S. ORTHOPAEDIC SURGERY PATIENT QUESTIONNAIRE Date of Examination Office Location Name DOB Age Soc. Sec. # Address City Telephone Number ( State Zip ) Height ft. in. Right-handed
Questionnaire 3. (only to be filled out when submitting blood and stool sample) This box will be filled out by the practice team
Questionnaire 3 (only to be filled out when submitting blood and stool sample) Date This box will be filled out by the practice team Patient-ID Barcode on labels Dear participant, We are pleased that you
LAWRENCE D. SCHUSTER, M.D., PH.D., F.A.C.P., F.A.C.E Central Office 255 PINEHURST BLDG, 4999 FRANCE AVE S., MINNEAPOLIS MN 55410
Patient Name Date PHYSICIAN INFORMATION REFERRING PHYSICIAN Name and Address of Referring Physician (this must be filled in) PRIMARY PHYSICIAN Name and Address of Family Physician, Gynecologist or Internist
PATIENT INFORMATION SPOUSE INFORMATION REFERRAL INFORMATION INSURANCE INFORMATION IN CASE OF EMERGENCY
Today s date: PATIENT INFORMATION Patient s Last name: First: Middle: Physician Name: Mr. Sex: Marital status (circle one) Single / Mar / Div / Sep / Wid Mailing address: City: State: ZIP Code: D.O.B:
Living Donor Kidney Program - Multi-Organ Transplant
Living Donor Kidney Program - Multi-Organ Transplant Toronto General Hospital, University Health Network 585 University Avenue Peter Munk Building 12 th Floor Room 100 G Toronto, ON M5G 2N2 Tel: 416-340-4800,
YOU MUST COMPLETE THE FOLLOWING FORM IN ITS ENTIRETY PRIOR TO YOUR APPOINTMENT. VIA OUR SECURE 2. FAX:
North Shore Gastroenterology Associates, P.C. 233 E. Shore Rd., Suite 101 Great Neck, NY 11023 Phone: 516-487-2444 Fax: 516-487-2446 www.northshoregastro.com YOU MUST COMPLETE THE FOLLOWING FORM IN ITS
GUADALUPE ENT, P.A. JENNIFER G. HENNESSEE, M.D. MAANSI DOSHI, D.O. LISA M. WRIGHT, PA
GUADALUPE ENT, P.A. JENNIFER G. HENNESSEE, M.D. MAANSI DOSHI, D.O. LISA M. WRIGHT, PA Patient Profile Last Name First Name Middle Name of Birth Gender Social Security Number Marital Status Email Race Ethnic
EYECARE REGISTRATION AND HISTORY
EYECARE REGISTRATION AND HISTORY PATIENT INFORMATION INSURANCE Date Who is responsible for this account? Patient Relationship to Patient Address Insurance Co. Group # City State Zip Is patient covered
Olympia Family Medicine 5949 Harbour Park Drive Midlothian, VA 23112
Olympia Family Medicine 5949 Harbour Park Drive Midlothian, VA 23112 Patient Registration Date Name DOB Age SSN Sex: M F Address City State Zip Code Home Phone # Cell Phone # Work Phone Occupation Employer
Female Health History Form Endo 9/2018
Female Health History Form Endo 9/2018 Date of Birth: Date of Appointment: Nickname or Name you like to be called: Who Referred you? [ ] OB/GYN Physician [ ] OB/GYN NP/Midwife [ ] Non OB/GYN Physician
ELBOW - New Patient Intake Form
Place label here Kristofer J. Jones, M.D. ELBOW - New Patient Intake Form Name Date Occupation _ Age DOB 1) Were you referred to this office? No Yes, Name 2) Who is your Internist or Primary Care Physician?
Adult History Form. Personal Information. Name: Birthdate: Age: Social Security number: Street Address: Cell:
Date: Adult History Form Please complete this detailed history form and return it to the front desk. If you have any questions or need assistance with anything, please let us know. Personal Information
Medicare Annual Wellness Visit Questionnaire 1} 3} 5} 2} 4} 6} 1} 3) 5) 2) 4) 6) 1} 4) 2} 5) Date: Name: LAST FIRST MIDDLE
DATE OF BIRTH: ADDRESS: Street or PO Box Town/City State Zip code TELEPHONE: H: W: C: GENDER: M F REFERRED BY: RELATIONSHIP: TELEPHONE: H: W: C:
VERMONT TECH DEPARTMENT OF DENTAL HYGIENE DATE: NAME: DATE OF BIRTH: EMAIL ADDRESS: ADDRESS: Street or PO Box Town/City State Zip code TELEPHONE: H: W: C: GENDER: M F REFERRED BY: IN CASE OF EMERGENCY
First Name Middle Name Suffix Sr. Jr. 111
New Patient Profile Today's Date Title Mr. Mrs. Ms. Miss Dr. Prof. Rev. First Name Middle Name Suffix Sr. Jr. 111 Last Name Nick Name Address 1 SSN Address 2 Male Female Date of Birth / / A1 City State
Nicola McFadzean Ducharme, N.D. Emily Poccia, N.D.
Nicola McFadzean Ducharme, N.D. Emily Poccia, N.D. Dear New Patient: Thank you for choosing RestorMedicine as your healthcare provider. We are dedicated to making your experience a most satisfying one.
First Name Middle Name Suffix Sr. Jr. 111
New Patient Profile Today's Date Title Mr. Mrs. Ms. Miss Dr. Prof. Rev. First Name Middle Name Suffix Sr. Jr. 111 Last Name Nick Name Address 1 SSN Address 2 Male Female Date of Birth / / A1 City State
FRIENDLY SMILES COSMETIC DENTISTRY Dr. Brenda Barfield, DDS th Ave S, Suite F Fargo, ND 58103
Welcome to Friendly Smiles Cosmetic Dentistry. We sincerely appreciate you choosing our office for your dental and oral health needs. Please be assured that we will work hard to continually earn the trust
Nature Body Care Acupuncture Spring Hill Dr., Spring Hill, FL Office: Fax:
13017 Spring Hill Dr., Spring Hill, FL NAME DATE I. Goals: What would you most like to achieve through your work at the NBC Acupuncture Center? 1. 2. 3. 4. 5. II. Major Symptoms: Please list in order of
Biological Father s Social & Medical History
Biological Father s Social & Medical History Instructions for Completion: *Please print clearly using dark ink. *Complete all items. If you do not know the answer, please indicate unknown, or if it does
Engage Patients on the #1 Platform for Doctor-Patient Connections. Display Advertising Media Kit 2018
Engage Patients on the #1 Platform for Doctor-Patient Connections Display Advertising Media Kit 2018 This is the moment of truth for pharma advertisers, but only 1% of Americans make a doctor s appointment
Family doctor services registration
GMS1-JUL12_GMS 1 17/07/2012 13:15 Page 1 Family doctor services registration GMS1 Patient s details n Mr n Mrs n Miss n Ms Date of birth Surname First names Please complete in BLOCK CAPITALS and tick n
Female Health History Form Fertility 9/2018
Female Health History Form Fertility 9/2018 Name of Partner: Date of Birth: Date of Appointment: Nickname or Name you like to be called: Who Referred you? [ ] OB/GYN Physician [ ] OB/GYN NP/Midwife [ ]
Position you are applying for: Days Nights Mon Fri 4 on 4 off ... Nationality:...
JOB APPLICATION FORM Please return this form by email which is our preferred option or alternatively by post. To return by email: Please complete this form using only Adobe Reader or Acrobat software.
Vine Medical Group Patient Registration Form Your Information
Your Information Welcome to Vine Medical Group. In order for us to offer you the high standards of clinical care we give to our patients, we ask that you complete this registration form. Before we are
I. Goals: What would you most like to achieve through your work at Twelve Pathways Acupuncture?
NAME DATE I. Goals: What would you most like to achieve through your work at Twelve Pathways Acupuncture? 1. 2. 3. 4. 5. II. Major Symptoms: Please list in order of importance what symptoms are of concern
Medicare Health Risk Assessment Questionnaire
Medicare Health Risk Assessment Questionnaire Instructions: Please complete and return it in the self-addressed stamped envelope provided. If you have questions or need help completing the questionnaire,
FRIENDLY SMILES COSMETIC DENTISTRY Dr. Brenda Barfield, DDS th Ave S, Suite F Fargo, ND 58103
FRIENDLY SMILES COSMETIC DENTISTRY Welcome to Friendly Smiles Cosmetic Dentistry. We sincerely appreciate you choosing our office for your dental and oral health needs. Please be assured that we will work
CHILDREN S HISTORY FORM
NEUROPSYCHOLOGY ASSOCIATES, P.C. 6232 N. 7TH ST., STE 100 Phoenix, Arizona 85014 Office (602) 230-8324 Fax (602) 274-7402 CHILDREN S HISTORY FORM INSTRUCTIONS TO PARENTS: Please complete this form and
City: State: Zip Code: - Work: Primary Insurance Provider: Primary Insured s Name: DOB:
Velvet Counseling Stop hurting, Start healing Name: New Client Paperwork Date: Name of Parent or legal guardian (if under 18 years of age): Client s Social Security Number: Referred by: Date of Birth:
The Chest Wall Center at Cincinnati Children s Patient Questionnaire
Today s Date Patient Name First Middle Last Date of Birth Age Home Phone Cell Work Email(s) Address(es) Primary Care Doctor (PCP) PCP S Address Street Address City State Zip PCP S Phone Number Which surgeon
Application for Residential Services
Check for which program applying for: Macleigh/VA Beach Kilmarnock/Rappahanock Colonial Beach/Colonial Beach Lynchburg Garber Morris/Varina Bonnie/Stuarts Draft Saratoga/Winchester Tate/Ashland Mary Beth
ADULT PSYCHOLOGICAL HISTORY
ADULT PSYCHOLOGICAL HISTORY Name: Date of Birth: Address Why I came for this visit: Who lives with you? Occupation: [ ] Live alone [ ] Spouse [ ] Partner Education: [ ] High School [ ] Some College [ ]
2006 Community Connection and MO Go Local Statistics Report date: 04/15/06
2006 Community Connection and MO Go Local Statistics Statistic Apr May Jun (visits) 19,042 27,675 32,730 Community Connection unique visitors 8,489 14,054 18,920 Page views from MedlinePlus (visits) 1,194
NEW LIFE FOR YOUTH ENROLLMENT APPLICATION
FACILITY 2 FACILITY 1 NEW LIFE FOR YOUTH ENROLLMENT APPLICATION GENERAL INFORMATION FIRST NAME LAST NAME MIDDLE CURRENT EMAIL PHONE GENDER (Circle) M F DATE OF BIRTH ARE YOU A U.S. CITIZEN? Y N IF YES,
Patient Portal Instructions
` Patient Portal Instructions There are two ways to access the patient portal, you can either access it from the www.lkorthopedics.com website and then clicking on the link that is loacted on the bottom
INPATIENT AVERAGE CHARGES AND LENGTH OF STAY
DRG INPATIENT CHARGES AND LENGTH OF STAY DESCRIPTION LOS TOTAL CHARGES 066 INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION W/O CC/MCC* 5 $9,200 069 TRANSIENT ISCHEMIA 1 $1,647 074 CRANIAL & PERIPHERAL NERVE
Creating a new Basic Information Transaction
Adding Basic Medical Information The Basic Medical Information is a transaction that records data such as allergies, past medical and surgical history, etc. It effectively acts like a summary chart in
Module 7 Family History of Mental Health Zivin et al
Module 7 Family History of Mental Health Zivin et al Calculated field needed: ne Other section variables needed: C27, A0, Fills: New Fill {FL_RCONDITIONS} constructed as follows: IF V3_EVERDEPRSSN = YES
New Student-Athlete Checklist
New Student-Athlete Checklist Pre-Participation Physical (must use form attached) Complete Athletic Training Forms online (see attached instructions) BESS/SCAT/ImPact Test (when arrive) Should you have
Biological Mother s Social & Medical History
Biological Mother s Social & Medical History Instructions for Completion: *Please print clearly using dark ink. *Complete all items. If you do not know the answer, please indicate unknown, or if it does
Item Field Format Position Position. Description
1 RecordType varchar(1) 1 1 B = Details for new V21 PTC MOR C = Details for new V22 PTC MOR D = for Details for new 2017 PTC model MOR - non-pace and non-esrd benes 2 HICN varchar(12) 2 13 Alphanumeric
De Wester Comprehensive Evaluation Form- New Patient Part I (DCEF-NP I)
De Wester Comprehensive Evaluation Form- New Patient Part I (DCEF-NP I) Please fill out the whole form; this is essential for performing a thorough evaluation. You may circle NONE for sections that you
BIOPSYCHOSOCIAL HISTORY
BIOPSYCHOSOCIAL HISTORY PRESENTING PROBLEMS Presenting problems Duration (months) Additional information: CURRENT SYMPTOM CHECKLIST (Rate intensity of symptoms currently present) None This symptom not
Ask your doctor about getting a prescription for 90-days.
CVS/caremark Mail Service Pharmacy Program User Guide Healthy Advantage Plus HMO Getting started is easy! If you need your prescription filled right away, ask your doctor to write two prescriptions for
Road Map for CAT4 Suite. CAT4 Road Map. Road Map for CAT4 Suite
Road Map for CAT4 Suite CAT4 Road Map Road Map for CAT4 Suite The Pen CS Clinical Audit Tool (CAT Plus Suite) is an extraction tool that takes a snapshot of your clinical data and allows you to analyse
My Care Plus Your reference guide. MyCarePlusOnline.com
My Care Plus Your reference guide. MyCarePlusOnline.com Your personal and health information is protected and secure on My Care Plus, as directed by our privacy policy. 2 Table of Contents 1) My Care Plus...
PATIENT INFORMATION PLEASE PRINT CLEARLY & PROVIDE PHOTO ID
PATIENT INFORMATION PLEASE PRINT CLEARLY & PROVIDE PHOTO ID Patient Name. Sex { } M { } F LAST FIRST MIDDLE INITIAL Birthdate. /. /... Age Social Security No.. Marital Status { } Single { } Married { }
Please mail all forms to:
Please mail all forms to: NKSS Admission, YWAM-AIIM 10211 Bollenbaugh Hill Rd, WA 98272 U.S.A Email : nkss@ywam-aiim.org Fax : 1-360-794-1997 Please mail all forms to: NKSS Admission, YWAM-AIIM 10211 Bollenbaugh
Application Form for Employment
PLEASE COMPLETE ALL FIELDS ON THIS FORM ENSURING THAT ALL INFORMATION IS CORECT THE BEST OF YOUR KNOWLEDGE IF A SECTION DOES NOT APPLY TO YOU PLEASE ENTER *N/A*- BLANK SECTIONS MAY DELAY YOUR APPLICATION
1. Study Registration. 2. Confirm Registration
USER MANUAL 1. Study Registration Diabetic patients are more susceptible to experiencing cardiovascular events, but this can be minimized with control of blood glucose levels and other risk factors (blood
LibreHealth Electronic Health Record
1 of 10 LibreHealth Electronic Health Record The LibreHealth EHR log in page can be accessed using Google Chrome and other common browsers. LibreHealth EHR is an open source EHR which means the programming
Mission Lipid Data Management Software User s Guide
Mission Lipid Data Management Software User s Guide V1.0 September 2018 Table of Contents 1. Overview...1 1.1 About the Mission Lipid Data Management Software...1 1.2 System Requirements...1 1.3 Materials
Using the Health Indicators database to help students research Canadian health issues
Assignment Using the Health Indicators database to help students research Canadian health issues Joel Yan, Statistics Canada, joel.yan@statcan.ca, 1-800-465-1222 With input from Brenda Wannell, Health
Jubilee School of Missionary Renewal
Jubilee School of Missionary Renewal YWAM-AIIM Monroe, Washington GUIDE TO COMPLETING APPLICATION Thank you for applying to JSMR(Jubilee School of Missionary Renewal) of YWAM-AIIM. You are encouraged to
Catskill Regional Medical Center Average Charge Per Inpatient Case - based on MS DRG
Per Inpatient Case - based on MS DRG 003 ECMO or trach w MV 96+ hrs or pdx exc face, mouth & neck w maj O.R. 343,389 004 Trach w MV 96+ hrs or pdx exc face, mouth & neck w/o maj O.R. 217,158 054 Nervous
PQRI Made Easy By Kelly Skinner and Claudia Tannous
PQRI Made Easy By Kelly Skinner and Claudia Tannous What is PQRI and why should we do it? PQRI stands for: Physician Quality Reporting Initiative PQRI has been developed to provide physicians with an opportunity
USER MANUAL VP PLANNING
USER MANUAL VP PLANNING 1.0 Mobile application ios Visible Patient SAS RCS Strasbourg TI 794 458 125 1 place de l'ho pital 67000 Strasbourg, FRANCE Share capital: 58330 Tel.: 33 (0)3 88 11 90 00 Fax: 33
Healthwise Knowledgebase and Healthwise Spanish Knowledgebase Implementation Guide - Hosted
Healthwise Knowledgebase and Healthwise Spanish Knowledgebase Implementation Guide - Hosted A Prescription-Strength Information Resource Guide Featuring Ix Indexing Details Product, Implementation, and
HISTORY OF THE INJURY:
Patient Information: Name: Age: _ Date: _ Address: (complete mailing address) _ Phone No.: (_) FAX:_ EMAIL: Date Of Birth: _ Soc. Sec. No.: Male Female * Right Handed Left Handed Both * Height: _ Weight:
The Cochrane Library
The Cochrane Library August 2010 Updated 13/02/2012 What is the Cochrane Library? The Cochrane Library is a collection of six databases that contain different types of highquality, independent evidence
USER MANUAL VP PLANNING
USER MANUAL VP PLANNING 1.0 Mobile application Android Visible Patient SAS RCS Strasbourg TI 794 458 125 1 place de l'ho pital 67000 Strasbourg, FRANCE Share capital: 58330 Tel.: 33 (0)3 88 11 90 00 Fax:
Average DRG DRG Description
s by DRG 64 INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION W MCC $23,330 65 INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION W CC OR TPA IN 24 HRS $23,948 66 INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION
DRG DRG Description Average Charges 835 ACUTE LEUKEMIA W/O MAJOR O.R. PROCEDURE W CC $ 282 ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE W/O CC/MCC $
DRG DRG Description Average Charges 835 ACUTE LEUKEMIA W/O MAJOR O.R. PROCEDURE W CC $ 35,880.75 281 ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE W CC $ 30,429.00 280 ACUTE MYOCARDIAL INFARCTION, DISCHARGED
2018 Partners in Excellence Executive Overview, Targets, and Methodology
2018 Partners in Excellence Executive Overview, s, and Methodology Overview The Partners in Excellence program forms the basis for HealthPartners financial and public recognition for medical or specialty
DEMOGRAPHIC INFORMATION, New Patient
DEMOGRAPHIC INFORMATION, New Patient Patient Information PCP: Patient Name: Mailing Address: Primary Phone: ok to leave brief msg? ok to leave detailed msg? Second Phone: ok to leave brief msg? ok to leave
CLINTON COUNSELING CENTER STUDENT SOCIAL MEDICAL QUESTIONNAIRE
CLINTON COUNSELING CENTER STUDENT SOCIAL MEDICAL QUESTIONNAIRE Please respond to ALL questions/information. There are multiple two sided pages. Check to be sure you have completed them all. Provide the
2015 Partners in Excellence Executive Overview, Targets, and Methodology
2015 Partners in Excellence Executive Overview, s, and Methodology Overview The Partners in Excellence program forms the basis for HealthPartners financial and public recognition for medical or specialty
NoteSwift for Aprima
NoteSwift for Aprima Tips and T ricks to get the Most out of Your EHR NoteSwift 4989 Peachtree Parkway Peachtree Corners, GA 30092 www.noteswift.com 07/30/2013 1 NoteSwift for Aprima NoteSwift for Aprima
MOE-OBS Challenge Programme - FormSG E-Registration User Guide
MOE-OBS Challenge Programme - FormSG E-Registration User Guide Step 1: 1. Please proceed to the FormSG link http://bit.ly/moe-obs_04-08nov2019_gdlss to begin the e-registration. Step 2: Please note that
New Student-Athlete Checklist
New Student-Athlete Checklist Pre-Participation Physical (must use form attached) Verify Primary Insurance(see attached instructions) Complete Athletic Training Forms online (see attached instructions)
DISCIPLESHIP TRAINING SCHOOL YWAM-AIIM MONROE, WASHINGTON GUIDE TO COMPLETING STUDENT APPLICATION
DISCIPLESHIP TRAINING SCHOOL MONROE, WASHINGTON GUIDE TO COMPLETING STUDENT APPLICATION Thank you for applying to AIIM-DTS. You are encouraged to apply early, at least two months prior to the start of
Portneuf Valley Family Center, Inc. Comprehensive Diagnostic Assessment-Consumer Report
Consumer Name: Age: DOB: M / F Address Phone: School/Work: Parent/Guardian Cell: Work: Home: Emergency Contact Information: Contact: Phone: Relationship: Services offered at Portneuf Valley Family Center
2017 Partners in Excellence Executive Overview, Targets, and Methodology
2017 Partners in Excellence Executive Overview, s, and Methodology Overview The Partners in Excellence program forms the basis for HealthPartners financial and public recognition for medical or specialty
Our Fee for Service Patient Price. Self Pay Price Elsewhere
DPC Services & Savings - February 2019 Mind & Body Christian Health Group, LLC Appointment Types Reason for the Appointment Service Patient s Out of Network General Adult Annual Physical (60 minute face
How To Log Into MDX. How To Print Your Memberships MDX Forms
How To Log Into MDX 1. Type https://axis.mdxnet.com into your Internet Browser 2. Enter account ID 119 3. Enter you User Name 4. Enter your Password 5. Click Login Button AV Form or Member Information
Facts about long term conditions. Our approach
Introduction my mhealth create digital solutions for the management of long term conditions. Evidence based, and highly secure, my mhealth provide a suite of solutions to manage patients with COPD, Asthma,
User Guide Chronic Disease Management Tariffs e-form
User Guide Chronic Disease Management Tariffs e-form Page 1 of 15 Table of Contents Computer Requirements... 3 Accessing the e-form... 3 Are eforms Secure?... 4 Completing the Chronic Disease Management
INSCRIBE SHORTCUT PROGRAM USING ASR-ENHANCED SHORTCUTS WITH STRUCTURED
INSCRIBE SHORTCUT PROGRAM USING ASR-ENHANCED SHORTCUTS WITH STRUCTURED TABLE OF CONTENTS WEEK 6: CTRL + X, CTRL + C, CTRL + V, CTRL + DELETE, CTRL + BACKSPACE... 2 CTRL + X (Cut selected text)... 2 CTRL
Status of Young Women & Girls in Illinois: Health
Health 1 Status of Young Women & Girls in Illinois: Health Prepared by Center for Urban Research and Learning Loyola University Chicago * * This research was completed by the Loyola University Chicago
Centers for Disease Control and Prevention National Center for Health Statistics
Wireless-Only and Wireless-Mostly Households: A growing challenge for telephone surveys Stephen Blumberg sblumberg@cdc.gov Julian Luke jluke@cdc.gov Centers for Disease Control and Prevention National
Last updated March 2019
Last updated March 2019 All inpatient stays require authorization All provided by non-contracted providers require pre-authorization SoCO/NoCO (POS 11) - For contracted providers in office specialty do
Annotating PDFs for ereturn version 1.0; August 28, 2007; full release
Annotating PDFs for ereturn version 1.0; August 28, 2007; full release 1. Introduction eproof files are self-contained PDF documents for viewing on-screen and for printing. They contain all appropriate
Patient Handbook. Version 1: June
HackensackUMC MyChart Patient Handbook Version 1: June 2014 1 HackensackUMC MyChart Patient Handbook Important Information... 4 Important Resources...5 MyChart Activation Code... 6 MyChart Activation Code
NEUROLOGY REFERRAL USER GUIDE
NEUROLOGY REFERRAL USER GUIDE To begin, click the Referrals tab from across the top menu. Select relevant hospital from drop down list and select referral type Neurology Referral. You will be presented
Signing up for My Lahey Chart
Signing up for My Lahey Chart What is My Lahey Chart? My Lahey Chart is a helpful service that allows you to connect with your doctor and your health information online, anytime. Using your personal computer
CERTIFIED HYPERTENSION CLINICIAN EXAMINATION
CERTIFIED HYPERTENSION CLINICIAN EXAMINATION Handbook for Candidates Application Deadline Examination Window February 9, 2018 February 24 March 10, 2018 July 20, 2018 August 25 September 8, 2018 SPONSORED
Peachtree Spine Physicians PATIENT INFORMATION
Peachtree Spine Physicians PATIENT INFORMATION Name: «PName» of Birth: «PDOB» Address: «PStreet1» Social Security #: «PSSN» City: «PCity» Sex: «PSex» State: «PState» Zip: «PZipCode» Marital Status: «PMaritalStatus»
Last updated May 2018
Last updated May 2018 All inpatient stays require authorization All provided by non-contracted providers require pre-authorization SoCO/NoCO (POS 11) - For contracted providers in office specialty do not
Contents. Making Sense of Statistics 00 Getting Personal: Factors that Modify Your Risk 00 It s a Numbers Game 00
Recto Runninghead v Contents Foreword by Mark H. Greene, M.D. 00 Acknowledgments 00 Introduction 00 Part I. Understanding Cancer, Genetics, and Risk Chapter 1. Breast and Ovarian Cancer Basics 3 Most Cancers
INTRODUCTION to SAS STATISTICAL PACKAGE LAB 3
Topics: Data step Subsetting Concatenation and Merging Reference: Little SAS Book - Chapter 5, Section 3.6 and 2.2 Online documentation Exercise I LAB EXERCISE The following is a lab exercise to give you
Ultrasound Stimulator CWM302 CWM302. Ultrasound Stimulator INSTALLATION & OPERATIONS MANUAL
INSTALLATION & OPERATIONS MANUAL 2 TABLE OF CONTENTS NOTES FOR SAFETY.3 EQUIPMENT AND FUNCTIONS...5 GENERAL FEATURES SAFETY FEATURES 1. ACCESSORY ILLUSTRATOR 2. OUTPUT BOARD AND OUTPUT MANUAL 3. MODE PROGRAMS
2018 Summer Camp Registration Form
INDEPENDENT HEALAMILY BRANCH YMCA 2018 Summer Camp Registration Form Child s Information Name (first/middle/last) Office Use Only [ ] Received registration packet Initials Nickname [ ] Male [ ] Female
Clinical Database applications in hospital
Clinical Database applications in hospital Mo Sun, Ye Lin, Roger Yim Lee sun2m, lin2y, lee1ry@cmich.edu Department of Computer Science Central Michigan University Abstract Database applications are used