Medical History Questionnaire
|
|
- Bertram Rice
- 6 years ago
- Views:
Transcription
1 Medical History Questionnaire Name: DOB: : Referring Physician: Primary Complaint: Dizziness Blacking out/fainting Lightheadedness Imbalance Falling Vertigo (spinning) Blurred Vision Unsteadiness Hearing Loss Ringing in the ears Ear Pain Headaches Nausea/Vomiting Tingling Hands/Feet/Lips Numb Feet Neck Pain Other: History of Symptoms: When did the first episode occur (date): The onset was Sudden Gradual Overnight Others The progress of the symptoms are Getting better ---- Staying the same -- Worsening How frequent are the symptoms occur? Constant Intermittent Are your symptoms made worse by any of the following? Check all that apply: Lying down/rolling in bed Sitting up/standing up Walking in the dark Walking on uneven surfaces Coughing/sneezing/nose blowing Hot baths or showers Menstrual cycle (if applicable) Supermarket aisles/malls/tunnels Automobile rides Windshield wipers Loud sounds Restaurants or movie theaters Reading Turning your head when walking Exercise Reaching or bending Stress or nerves Is there anything else you know of that will provoke or make your dizziness worse? Do you have symptoms that occur in spell? Yes ---- No If yes, check all symptoms that occur in spells (no matter how long the spell): Off balance when standing or walking Light-headed or fainting sensation Off balance when sitting or lying down Tumbling or spinning sensation Check the one that (on the average) describes the length of the typical, single spell: Measured in seconds Measured in minutes to hours but less than 24 hours Measured in hours to days but less than 7 days Measured in days, can last continuously for weeks ACMC-Marshall Market Street: 1420 East College Drive Marshall, MN (507) ACMC#1173 REV. 01/17 1
2 Check the one that (on the average) describes how frequently your spells are occurring: Daily or multiple times per day Several times in a 2-month interval Multiple times per week Several times in a 6-month intervals Multiple times per month Several times in a 12-month interval Do you use a cane, walker, or furniture/walls to keep your balance? Yes ---- No Does poor lighting affect your balance? Yes ---- No Are uneven surfaces (grass, gravel, hills) difficult to negotiate? Yes ---- No Have you fallen because of these symptoms? Yes ---- No Number of falls: Number of Near-Falls : Do you tend to fall in one direction? Yes... No If yes, which direction? Do the symptoms seem to be related to your cycle? (if applicable) Yes ---- No If so, how? Are you currently pregnant? (if applicable) Yes ---- No Due : This section deals with headaches. It is important to complete it as indicated. Have you had a total of 5 or more headaches (does not matter how severe) in your lifetime? Yes ---- No Have you ever had a headache that was severe enough to make you stop your activity and sit or lie down? Yes ---- No Have you ever experienced a temporary change in your vision (jagged lines, color spots or lightning bolts)? Yes ---- No Have you ever been diagnosed with migraine headaches? Yes ---- No (If you have answered No to all four above, then go to the section on Vision. ) (If you have answered Yes to 1, 2, 3, or 4 above, then please complete section below.) Please check all of the following that you have experienced: Headaches where the discomfort localizes to a region(s) of the head Increased sensitivity to light during a headache A headache provoked by a sudden bright light, such as sunlight Increased sensitivity to sound during a headache Increased chance of headache around your menses (if applicable) Increased sensitivity to odors during a headache Change in headache behavior with pregnancy or after (if applicable) Motion sickness as young child prior to puberty Certain foods or beverages increase the chances of a headache Nausea and/or vomiting with a headache Headaches associated with your problems of dizziness or imbalance Headache that lasted longer than 24 hours Headaches where the pain throbs or pulses At what age do you first remember having a headache? Under age 12 In your twenties or thirties In your fifties In your teens In your forties In your sixties, seventies od eighties Have headaches been a significant problem with the past 6 months? Yes ---- No ACMC-Marshall Market Street: 1420 East College Drive Marshall, MN (507) ACMC#1173 REV. 03/23/17 2
3 Vision: Have you recently got new lenses? Yes ---- No Last eye exam: Has your vision changed as a result of your current symptoms? Yes ---- No Please describe: Hearing: Do you have any of the following ear symptoms? Loss of hearing? Yes No Which ear? Left --- Right - Both The progress of the symptoms are Getting better ---- Staying the same -- Worsening Wear hearing aids? Yes No Which ear? Left --- Right - Both Ringing/noise in your ears? Yes No Which ear? Left --- Right - Both How frequent are the symptoms occur? Constant Intermittent Have you ever had a hearing test done? Yes ---- No If yes, Where: When: Neurologic: Do you experience any of the following? Doubled or blurred vision Numbness of face/extremities Weakness in arms/legs Poor coordination in arms/legs Confusion or loss of consciousness Swallowing/Speech difficulties Evaluation, Treatment & Testing: Other healthcare providers you have seen for these symptoms: Surgery, procedures and/or therapy for these symptoms: Previous tests for these symptoms: Brain or Cervical Spine CT Scan Where: When: Brain or Cervical Spine MRI/MRA Where: When: ENG/VNG (Vestibular Testing) Where: When: Other: Allergies: (please describe reaction) Seasonal Allergies: Environmental Allergies (Dust / Latex): Drug Allergies: ACMC-Marshall Market Street: 1420 East College Drive Marshall, MN (507) ACMC#1173 REV. 03/23/17 3
4 Medications & Supplements: Medication/Supplement Dosage Times per day Start when? Self& Family Medical History: Diagnosis Self Mother Father Grandparent Alzheimer s Epilepsy/Seizures Parkinson s Multiple Sclerosis Panic Attacks Depression Anxiety Cancer/ Tumors Glaucoma Macular Degeneration Migraines Sleep Apnea Fibromyalgia Osteoporosis Arthritis Diabetes Thyroid disease High Blood Pressure Anemia Low Blood Pressure Heart Disease Irregular Heartbeat High Cholesterol Stroke / TIA Meniere s Disease Peripheral Neuropathy Sciatica Cataract If removed, when? Neck of onset? Explain: Low Back Pain of onset? Explain: Lower Extremity Joint Injury of onset? Explain: ACMC-Marshall Market Street: 1420 East College Drive Marshall, MN (507) ACMC#1173 REV. 03/23/17 4
5 Health History: Hospitalizations Surgeries Serious Injury/Illness Patient s Information Marital Status: Single Married/Divorced/Separated --- Widowed Occupation: Living Situation: House Apartment ---- Condo Nursing Home Assisted Living Stairs? Yes ---- No Who do you live with: Spouse Family Significant Other --- Alone -- Other: List your hobbies/activities: Please indicate your activity level: - Sedentary Light Moderate Vigorous Habits Caffeine Yes No Beverages per day: Smoking Yes No Cigarettes/packs per day: Alcohol Yes No Drinks per week/month: Recreational drug use Yes No If so, what do you use? How often do you use it? times per day week For how long? ACMC-Marshall Market Street: 1420 East College Drive Marshall, MN (507) ACMC#1173 REV. 03/23/17 5
PATIENT REGISTRATION
PATIENT REGISTRATION **Please PRINT clearly and fill out form COMPLETELY and hand all insurance cards for copying** First Name: Last Name: Middle Initial: Address:------------ Apt#: City: State: Zip: Date
More informationDisease Prevention and Health Maintenance
1 EraCare Physicians Internal Medicine - Primary Care 1920 Don Wickham Dr. Suite 335 Clermont, FL 34711 Phone: (352) 708-8211 Fax: (352) -227-1701 New Patient Medical History Please complete this two-sided
More informationHeight Weight BP Pulse
9 Starbrush Circle Suite 201 P: 985-259-7774 Covington, La 70433 F: 985-259-7775 Website: www.vantagepointcovington.com Email: info@vantagepointcovington.com Height Weight BP Pulse Whom may we thank for
More informationMEDICATION GUIDE RIBAVIRIN TABLETS Rx Only Read this Medication Guide carefully before you start taking ribavirin tablets and read the Medication
MEDICATION GUIDE RIBAVIRIN TABLETS Rx Only Read this Medication Guide carefully before you start taking ribavirin tablets and read the Medication Guide each time you get more ribavirin tablets. There may
More informationSYMPTOM CONTROL? PEDIATRICS
IS YOUR CHILD READY FOR SYMPTOM CONTROL? PEDIATRICS For children ages 6-17 with moderately to severely active Crohn s disease or ulcerative colitis (UC) who haven t responded well to other therapies SELECTED
More informationLead In Water Supply Pipes
Lead In Water Supply Pipes By Keith L. Phillips Exposure to lead in the home occurs primarily via two ways: the ingestion and/or inhalation of lead dust from paint and the consumption of water contaminated
More informationMedical History Questionnaire
Medical History Questionnaire Instructions Human Resources Instructions: 1. Complete Section 1 of Medical History Questionnaire; 2. Determine whether candidate must complete Section 2A only or Section
More informationNEW PATIENT REGISTRATION FORM
NEW PATIENT REGISTRATION FORM Patient (Legal) Name: Nickname: SSN (> Age 18): Date o f Birth: Sex: Male Female M ailing Hom e Address: Street/PO Box Address: Street City State Zip Code City State Zip Code
More informationA GUIDE TO THIS REFLECTIONS B RESEARCH STUDY IF YOU RE FIGHTING BREAST CANCER, YOU RE NOT ALONE
A GUIDE TO THIS REFLECTIONS B327-02 RESEARCH STUDY IF YOU RE FIGHTING BREAST CANCER, YOU RE NOT ALONE Do you have breast cancer that has spread to outside the breast? Has your tumor tested positive for
More informationBritish Midland Regional Limited Cabin Crew Employment Application Form
British Midland Regional Limited Cabin Crew Employment Application Form Please complete this form clearly and accurately, giving as many details as possible of your skills and experience relating to this
More information2 Responsible Party(If different from section 1)
1 Name Welcome Thank you for selecting our Dental Health Care team! We strive to provide you with the best possible dental care. To help us provide personalized and comfortable dentistry, please fill out
More informationFMLA / FAMILY MEDICAL LEAVE ACT POLICY Ingham County
What is it? FMLA / FAMILY MEDICAL LEAVE ACT POLICY Ingham County FMLA is a federal law requiring employers to grant up to 12 weeks of unpaid leave per year to their employees due to the following reasons.
More informationRequest for Reasonable Accommodation Americans with Disabilities Act (ADA)
Request for Reasonable Accommodation Americans with Disabilities Act (ADA) Date of Request: Employee s Name Employee s Work Phone Job Title Department What is the accommodation you are requesting? Please
More informationBrain Tumour Australia Information FACT SHEET 22 Clinical Trials: Questions and Answers
FACT SHEET 22 Clinical Trials: Questions and Answers What is a clinical trial? Clinical trials are research studies that answer scientific questions and try to find better ways to prevent, screen for,
More informationIf the air is moving (for example, by fans) and it is cooler than your body, it is easier for your body to pass heat into the environment.
https://www.labour.gov.on.ca/english/hs/pubs/gl_heat.php Page 1 of 5 APPENDIX E Heat Stress Issued: April 2008 Revised: June 2014 Content last reviewed: June 2014 See also: Heat Stress This guideline is
More informationAddress: Age: DOB: Occupation: Referred by: Primary Reason for Visit: Other Concerns: Number of Children: Ages:
Name: Date: Address: Home Phone: Cell Phone: E mail: Age: DOB: Occupation: Referred by: Height: Weight: Sex: M / F Primary Reason for Visit: Other Concerns: Single Married Divorced Widowed Number of Children:
More informationGreater Monmouth Neurology P.C. 130 Maple Avenue Suite 1-A Red Bank NJ, Phone Fax Please Print Clearly
130 Maple Avenue Suite 1-A Red Bank NJ, 07701 Phone 732-741-1378 Fax 732-741-1677 Please Print Clearly Dr. Schuber C. Fan Dr. Edgar Y. Chen Dr. Philip V. Ilaria Patient Name: Last First MI Home Address
More information4 th Annual Section of Labor and Employment Law Conference Chicago, IL November 3-6, 2010
4 th Annual Section of Labor and Employment Law Conference Chicago, IL November 3-6, 2010 FMLA Substantive Rights: Entitlements and Limitations Catherine J. Trafton Associate General Counsel International
More informationPATIENT REGISTRATION
Patient Information: PATIENT REGISTRATION Date: Name: (First) (Middle) (Last) Address: Social Security Number: Home phone: ( ) Date of Birth: Marital Status: Sex: Race: (please circle one) American Indian,
More informationATTACHMENTS. Attachment 1 "Your Rights under the FMLA of 1993" Notice to be posted of employee rights under FMLA.
File: GCBE-R ATTACHMENTS Attachment 1 "Your Rights under the FMLA of 1993" Notice to be posted of employee rights under FMLA. Attachment 2 "Certification of Health Care Provider" If requested, employee
More informationGUIDELINES FOR EMPLOYEE S HEALTH - AN USEFUL TOOL FOR WORKPLACE HEALTH PROTECTION
GUIDELINES FOR EMPLOYEE S HEALTH - AN USEFUL TOOL FOR WORKPLACE HEALTH PROTECTION Adriana Todea, MD Senior Occupational Health Physician - Institute of Public Health Bucharest, Romania I designed this
More informationFMLA Employer Response Form
FMLA Employer Response Form Employer Response to Employee Request for Family or Medical Leave (Optional: use form see 29 CFR 825.301 (Family and Medical Leave Act of 1993) U.S. Department of Labor Employment
More informationYour Rights. Family and Medical Leave Act of 1993
Your Rights Under The Family and Medical Leave Act of 1993 FMLA requires covered employers to provide up to 12 weeks of unpaid, job-protected leave to eligible employees for certain family and medical
More informationYou ve Got the POWER! What You Should Know About Clinical Trials
You ve Got the POWER! What You Should Know About Clinical Trials Project I.M.P.A.C.T. (Increase Minority Participation and Awareness of Clinical Trials) We want to help you and your family use medical
More informationSummary of the Family and Medical Leave Act of 1993
Summary of the Family and Medical Leave Act of 1993 The Family and Medical Leave Act of 1993 (FMLA) was enacted on August, 1993. It requires public agencies to provide up to twelve weeks (60 work days;
More informationDonor Informed Consent to Participate in Research
Donor Informed Consent to Participate in Research This is a consent form for a research study. This clinical trial is a research study to determine better treatment for patients with Multiple Myeloma (MM).
More informationINSURANCE INFORMATION
PERSONAL INFORMATION Patient Name Age Sex Date of Birth _ Parent Name (if minor) Patient Social Security # Address Home Phone_ City Zip Cellular Phone Employer E-mail Address Address Work Phone Zip Spouse
More informationEnoxaparin (Lovenox )
What is enoxaparin (Lovenox )? Enoxaparin is also called Lovenox Enoxaparin is an anticoagulant, or blood thinner, that works to prevent blood clots from forming in your body or treat blood clots after
More informationFAMILY AND MEDICAL LEAVE ACT OF 1993
Division of Administrative Services HUMAN RESOURCES FAMILY AND MEDICAL LEAVE ACT OF 1993 Employee Packet Division of Administrative Services HUMAN RESOURCES North End Center 300 Turner St. NW Suite 2300
More informationHuman Resources Section V, Page 1 of 9 Revision: January 28, 2008
Family And Medical Human Resources Section V, Page 1 of 9 History: First issued: 1993 Last revised: January 28, 2008 Authority Office of State Personnel, Board of Governors Title Family and Medical and
More information"Follow-Up Postal Survey 1" of the first-wave participants of the National Institute for Longevity Sciences - Longitudinal Study of Aging (NILS-LSA)
National Institute for Longevity Sciences - Longitudinal Study of Aging (NILS-LSA): A Follow-Up Study "Follow-Up Postal Survey 1" of the first-wave participants of the National Institute for Longevity
More informationM E M O R A N D U M OREGON DEPARTMENT OF FISH AND WILDLIFE
M E M O R A N D U M OREGON DEPARTMENT OF FISH AND WILDLIFE Attachment A DATE: FROM: TO: SUBJECT: Jerry Cotter, Safety & Health Manager Station Managers Respiratory Protection Medical Evaluations Enclosed
More informationBy Wilma Subra Subra Company P. O. Box 9813 New Iberia, LA
By Wilma Subra Subra Company P. O. Box 9813 New Iberia, LA 70562 337 367 2216 subracom@aol.com Two 6,130 horsepower natural gas-fired turbin driven centrifugal compressor units Fuel oil heater Emergency
More informationHealth risk assessment guidance for line managers
Health risk assessment guidance for line managers Contents 1 Introduction... 2 1.1 Purpose... 2 2 The five principles of risk assessment... 2 3 Health risk assessment process... 2 4 Additional information...
More informationSTN: BL /5234 HSTCL PAS April 14, 2009
Rx Only MEDICATION GUIDE REMICADE (Rem-eh-kaid) (infliximab) Read the Medication Guide that comes with REMICADE before you receive the first treatment, and before each time you get a treatment of REMICADE.
More informationFAMILY AND MEDICAL LEAVE ACT OF 1993
Division of Administrative Services HUMAN RESOURCES FAMILY AND MEDICAL LEAVE ACT OF 1993 Family Packet Division of Administrative Services HUMAN RESOURCES North End Center 300 Turner St. NW Suite 2300
More informationFrom Pre-Hire to Retire: Supporting Wellness in the Workplace and Return to Work Success
From Pre-Hire to Retire: Supporting Wellness in the Workplace and Return to Work Success Our Story Trusted advisors for Occupational Health and Wellness Founded in 2003 by Dr. Doug Friars as Focus Workplace,
More informationJR., M.D. TELEPHONE 626 FIRST STREET J. STEPHEN M.D. (478) MACON, GEORGIA JEFFERY C. HINSON, JR., M.D. FAX (478)
Eye Physicians' Association M.D. P.O. BOX 956 JR., M.D. TELEPHONE 626 FIRST STREET J. STEPHEN M.D. (478) 743-4666 MACON, GEORGIA 31201 JEFFERY C. HINSON, JR., M.D. FAX HOMER S. M.D., EMERITUS (478) 743-4740
More informationBenson Dermatology & Skin Cancer (PLEASE I'RlNT CLEARI/l') Full Name Home Phone( )--.. -- - Zip City ------- - - -- -- --State Soeial Security#. - -- -- ---- Email. @ Date of Birth - - -- - ------- - -
More informationUsing Complete Blood Cell Counts to Diagnose Disease
Physiology 2 Redwood High School Name Class Period Using Complete Blood Cell Counts to Diagnose Disease Background A healthy adult has about 4.5 to 5 million red blood cells and approximately 8,000 white
More informationWORKPLACE SAFETY AND INSURANCE APPEALS TRIBUNAL
2003 ONWSIAT 634 WORKPLACE SAFETY AND INSURANCE APPEALS TRIBUNAL DECISION NO. 425/03 [1] This appeal was held in London on February 19, 2003 before Vice-Chair, T. Carroll. THE APPEAL PROCEEDINGS [2] The
More informationWEEKLY SAFETY MEETING All Euramax Subsidiaries STRESS. Safety Meeting Contents. Meeting Notice. Leaders Guide. Employee Handout.
Safety Meeting Contents Meeting Notice Leaders Guide Employee Handout Employee Quiz Meeting Sign-In Sheet Employee Puzzle PRIOR TO THE WEEKLY MEETING: - Post the meeting notice by the timeclock - Read
More informationEBOLA CONTACT TRACING N.C. Case Investigation Form
EBOLA CONTACT TRACING N.C. Case Investigation Form E EID: NC EDSS Event: Below line is CDC FORM 1 - Ebola Case Investigation Form 11/13/2014 Ebola Viral Disease Case Investigation Form United States State/Local
More informationBy: Wilma Subra Subra Company
By: Wilma Subra Subra Company Waste---Non-Hazardous Wastes generated by the exploration, development and production of crude oil and natural gas are exempt by Federal law from being regulated as hazardous
More informationAVONEX Interferon beta-1a
AVONEX Interferon beta-1a Consumer Medicine Information What is in this leaflet This leaflet answers some common questions about AVONEX Solution for Injection (also known as 'Pre- Filled Syringe'). It
More informationMinistry of Education Youth and Culture/Ministry of Health School Health Programme
Appendix 1 Ministry of Education Youth and Culture/Ministry of Health School Health Programme STUDENT S MEDICAL REPORT Part A TO BE COMPLETED AND SIGNED BY PARENT/ LEGAL GUARDIAN NAME OF SCHOOL: ACADEMIC
More informationRx EDGE. Best Practices. Solutions at the Shelf programs from Rx EDGE. Pharmacy Networks. White Paper
Rx EDGE Best Practices Solutions at the Shelf programs from Rx EDGE White Paper Get the most from your Rx EDGE Solutions at the Shelf program Quantifiable, measurable, actionable these are words not often
More informationColumbiaDoctors. Adult New Patient Intake Form
Name: DOB: ColumbiaDoctors Adult New Patient Intake Form Page 1 of 4 Patient Information Last Name: ------------ First Name: ----------- DOB: --------- Gender: Home Phone: ------------Mobile Phone: ---------------
More informationColumbiaDoctors. Adult New Patient Intake Form
Name: DOB: ColumbiaDoctors Adult New Patient Intake Form Page 1 of 4 Patient Information Last Name: ------------ First Name: ----------- DOB: --------- Gender: Home Phone: ------------Mobile Phone: ---------------
More informationMental Health Intake Form
Mental Health Intake Form Please complete the information on this form and bring it to the first visit. It may seem long, but most of the questions require only a check. This form will be reviewed at your
More informationFMLA Notice to Employee
FMLA Notice to Employee FAMILY & MEDICAL LEAVE: YOUR RIGHTS AND OBLIGATIONS The City of Billings provides family and medical leave (FMLA) to eligible employees in accordance with the federal Family and
More informationThe Impact of an Aging Workforce on Safety and Claims
1 The Impact of an Aging Workforce on Safety and Claims As with other industries, the agribusiness industry has a work force that is older because people are working longer for various reasons and because
More informationMEDICATION GUIDE REMICADE (Rem-eh-kaid) (infliximab) What is the most important information I should know about REMICADE?
MEDICATION GUIDE REMICADE (Rem-eh-kaid) (infliximab) Read the Medication Guide that comes with REMICADE before you receive the first treatment, and before each time you get a treatment of REMICADE. This
More informationMEDICATION GUIDE REMICADE (Rem-eh-kaid) (infliximab)
MEDICATION GUIDE REMICADE (Rem-eh-kaid) (infliximab) Read the Medication Guide that comes with REMICADE before you receive the first treatment, and before each time you get a treatment of REMICADE. This
More informationTHE FAMILY AND MEDICAL LEAVE ACT
THE FAMILY AND MEDICAL LEAVE ACT The Family and Medical Leave Act of 1993 1 (FMLA) gives many workers the right to take time off from work because of their own serious illness, or the serious illness of
More informationSUMMARY DECISION NO. 2339/00. Disablement (nature of work); Forklift operator.
SUMMARY DECISION NO. 2339/00 Disablement (nature of work); Forklift operator. The worker appealed a decision of the Appeals Officer denying entitlement for a low back injury. The worker's condition was
More informationFORT LUPTON FIRE PROTECTION DISTRICT 1121 Denver Avenue Fort Lupton, Colorado POSITION DESCRIPTION COMMUNITY OUTREACH SPECIALIST
FORT LUPTON FIRE PROTECTION DISTRICT 1121 Denver Avenue Fort Lupton, Colorado 80621 POSITION DESCRIPTION POSITION: STATUS: EMPLOYMENT STATUS: WORK HOURS: SALARY RANGE: COMMUNITY OUTREACH SPECIALIST FULL-TIME;
More informationStress Management Policy
, Stress Management Policy January 2014 Also available in large print (16pt) and electronic format. Ask Student Services for details. www.perth.uhi.ac.uk Perth College is a registered Scottish charity,
More informationFamily and Medical Leave Employee Packet
Family and Medical Leave Employee Packet City of Missoula Notice to Employees The City of Missoula provides family and medical leave (FMLA) to eligible employees in accordance with the federal Family and
More informationAdprime Health. The #1 Online Health Ad Network. - comscore, May 2012, as Adprime Media Health
Adprime Health The #1 Online Health Ad Network - comscore, May 2012, as Adprime Media Health The Gateway to Reach Health Audiences Reach Largest health-dedicated network in the U.S. and GROWING. Targeting
More informationAVONEX. What is in this Leaflet. What AVONEX is used for. Before you use AVONEX. Interferon beta-1a. Consumer Medicine Information
Interferon beta-1a Consumer Medicine Information What is in this Leaflet This leaflet answers some common questions about AVONEX Solution for Injection (also known as 'Pre- Filled Syringe') and AVONEX
More informationSummer Youth Musical Theatre Workshop Application Form
Office Use Only: Date Rec d Full payment Rec d 2016 Summer Youth Musical Theatre Workshop Application Form PLEASE READ THIS APPLICATION CAREFULLY Please complete the entire application and mail it along
More informationThe 2016 HealthMine Digital Health Report
SPRING/SUMMER 2016 Copyright 2016 HealthMine, Inc. All rights reserved. The 2016 HealthMine Digital Health Report State and Impact of Digital Health Tools Table of Contents P 2 P3 Overview P4 Executive
More informationConsent Forms Wendy Doggett, June 28, 2012
Consent Forms Wendy Doggett, doggettw@ohsu.edu June 28, 2012 Today s topics Tips for consent form writing New consent form templates Consent Process, Consent Discussion http://www.hhs.gov/ohrp/policy/consent/
More informationMarathon Health: ehealth Portal User Guide
Marathon Health: ehealth Portal User Guide Getting Started Welcome Welcome to the Marathon ehealth Portal, your online resource for managing and achieving your personal health goals. This user guide will
More informationWelcome Back to the Framingham Heart Study
Framingham Heart Study Group 3 Exam 3 RESEARCH CONSENT FORM Welcome Back to the Framingham Heart Study Why is the research study being done? The Framingham Heart Study is a long term research study. The
More informationMore Effective Treatments for Multiple Myeloma Convention Connection: American Society of Hematology Meeting December 2010 Dan Vogl, M.D.
More Effective Treatments for Multiple Myeloma Convention Connection: American Society of Hematology Meeting December 2010 Dan Vogl, M.D. Please remember the opinions expressed on Patient Power are not
More informationWASHOE COUNTY. Family and Medical Leave Policy
WASHOE COUNTY Family and Medical Leave Policy I. Policy A. Eligibility B. Types of Leave Covered C. Definition of a Serious Health Condition D. Tracking FMLA Leave E. Intermittent Leave F. Substitution
More informationFREQUENTLY ASKED QUESTIONS
CLINICAL TRIALS FREQUENTLY ASKED QUESTIONS PARTICIPATING IN A CLINICAL TRIAL What is a clinical trial? Clinical trials are research studies that involve people. Through clinical trials, researchers find
More informationAPPLICATION FOR EMPLOYMENT AS AN INTERIM MANAGER
PO Box 493 Concord NSW 2137 02 8765 1200 Email: admin@blackadderassoc.com.au APPLICATION FOR EMPLOYMENT AS AN INTERIM MANAGER Address: APPLICANT INFORMATION Date of Surname Given Name (s) Birth: dd/mm/yyyy
More informationForm Name: Application For Employment Ref No: 008. Can we ring you at work? YES / NO
Post Applied for: Closing Date for Applications: Post Ref: How did you hear about the job? Completed forms should be returned to: Name and address Important Notice, please read: This home is committed
More informationC-Tech Industrial Group, Inc.
C-Tech Industrial Group, Inc. 2200 West Sixth Avenue El Dorado, Kansas 670042 Application for Employment Personal Information This application is used for all C-Tech Industrial Group, Inc. companies. Applicants
More informationMERCY FLEET Phone: Fax:
MERCY considers all applications for all positions without regard to race, color, religion, creed, gender, national origin, age, sexual orientation, marital, veteran or any other legally protected status.
More informationSPECSAVERS CORPORATE EYECARE Guide to DSE (display screen equipment) regulations
SPECSAVERS CORPORATE EYECARE Guide to DSE (display screen equipment) regulations EYES FOCUSSED ON THE JOB IN HAND Protect staff s eyes it s the law and makes sense Protecting employees eyesight against
More informationWorkplace Wellness Initiative
What is Workplace Wellness? Workplace wellness is defined as an organized, employersponsored program that is designed to support employees (and sometimes, their families) as they adopt and sustain behaviors
More informationGlobal Congress on Neurology & Neuroscience
Global Congress on Neurology & Neuroscience About the Conference: Gavin Conferences invites participants from all over the world to attend Global Congress on Neurology & Neuroscience. Neurology 2019 is
More informationHEALTH CLUB PROJECT. Record Book. Oregon State System of Higher Education. Federal Cooperative Extension Service. Oregon State College.
3 7!. QEGO STATE USR' O3Ic e 3 Name - Club No. R.F.D. or Age ---------------------- Street Address... OCUMEN LLEcTIo Town-------------------------------------------------- County----------------------------,
More informationPURITY AND SAFETY BEYOND ORGANIC
HEALTHY WEIGHT PURITY AND SAFETY BEYOND ORGANIC BEYOND ORGANIC Beyond Organic reflects our belief that our quality standards go beyond how and where an ingredient is grown. Instead we look to confirm
More informationRenew, Repair, Rejuvenate. Presented by: Clinton Howard at the 2012 Leadership Retreat Maui, Hawaii, September 29, 2012
Stem-Kine Renew, Repair, Rejuvenate Presented by: Clinton Howard at the 2012 Leadership Retreat Maui, Hawaii, September 29, 2012 I am pleased to have the opportunity to talk with you about one of the most
More informationGuidelines/Procedures
Guidelines/Procedures SUBJECT: Family and Medical Leave Guideline/Procedure for AR#: 6.09.001 Date Effective: 03/04/2015; amended 03/01/17 Purpose The HR Benefits office will manage the Family and Medical
More informationALLEGHENY COUNTY DEPARTMENT OF HUMAN RESOURCES
ALLEGHENY COUNTY DEPARTMENT OF HUMAN RESOURCES Policies and Procedures Family and Medical Leave Act Leave of Absence Policy Number: Employee Benefits, #18 Date Issued: February 24, 2015 This policy supersedes
More informationEmployers obligations and Employee entitlements when using Display Screen Equipment in Ireland
Corporate Eyecare www.visionexpress.ie/information/corporate-eyecare Employers obligations and Employee entitlements when using Display Screen Equipment in Ireland 2009 Health & Safety Authority Source:
More informationRecent evidence on psychogenic aspects of wind turbine syndrome
Recent evidence on psychogenic aspects of wind turbine syndrome A communicated disease? School of Public Health, University of Sydney Prof Simon Chapman AO PhD FASSA Twitter:simonchapman6 Critics claim
More informationWelcome to Buslink NT
Date: Your Name: Contact Number: 1. Casual School us Driver Position Description... 2 2. Self-Assessment Questionnaire... 3 3. Application Details for Employment... 4 4. Other Employment... 4 5. Drivers
More informationAnti-Harassment Policy Acknowledgment Form
Springfield, MA 01103-1410 SPRINGFIELD PUBLIC SCHOOLS - S PRINGFIELD, MASSACHUSETTS Anti-Harassment Policy Acknowledgment Form The Springfield Public Schools ( SPS ) Anti-Harassment policy, covering all
More informationCareer Profile Face Sheet/IPS Supported Employment Referral. Phone #2:
Career Profile Face Sheet/IPS Supported Employment Referral Person s Name: Client ID #: Address: Phone: Phone #2: Email: Date of referral: Primary MH worker: Best way to reach person: What is the person
More informationELLIOTT BAXTER & COMPANY LIMITED
ELLIOTT BAXTER & COMPANY LIMITED www.ebbpaper.co.uk PLEASE ENSURE THAT YOU COMPLETE ALL SECTIONS OF THIS APPLICATION FORM TO THE BEST OF YOUR ABILITY. IF YOU HAVE A DISABILITY WHICH MEANS THAT YOU ARE
More informationThe Employee s Guide to. the Family and Medical Leave Act. Wage and Hour Division
The Employee s Guide to the Family and Medical Leave Act Wage and Hour Division An Introduction to the Family and Medical Leave Act When you or a loved one experiences a serious health condition that
More informationGuidelines for the Medical Clearance of Designated Ebola Caregivers in US Hospitals
Guidelines for the Medical Clearance of Designated Ebola Caregivers in US Hospitals American College of Occupational and Environmental Medicine Medical Center Occupational Health Section Prepared by the
More informationFrom Stem Cell to Any Cell
sciencenewsforkids.org http://www.sciencenewsforkids.org/2005/10/from-stem-cell-to-any-cell-2/ From Stem Cell to Any Cell By Emily Sohn / October 11, 2005 For maybe a day, about 9 months before you were
More informationHow New Media Changes Pharmaceutical DTC Advertising
How New Media Changes Pharmaceutical DTC Advertising Thursday, April 16, 2009 Meredith Abreu Ressi Vice President of Research, Manhattan Research mressi@manhattanresearch.com Jeff Hitchcock President and
More informationWill Stem Cells Finally Deliver Without Controversy?
Will Stem Cells Finally Deliver Without Controversy? Keith Gary, Ph.D. Director of Program Development Kansas City Area Life Sciences Institute Olathe North Life Sciences 1 February 2012 What s the Buzz?
More informationMedical Leave Policy. Marathon Petroleum Medical Leave Policy
Marathon Petroleum Medical Leave Policy Effective January 1, 2018 Table of Contents I. Introduction... 1 II. Eligibility... 1 III. Qualifying for Medical Leave... 2 IV. Effective Date... 2 V. Duration
More informationAtlantic County Division of Public Health Questions and Answers about Cyanide
What cyanide is Atlantic County Division of Public Health Questions and Answers about Cyanide Cyanide is a rapidly acting, potentially deadly chemical that can exist in various forms. Cyanide can be a
More informationFamily and Medical Leave Employee Packet A
Family and Medical Leave Employee Packet A Leave for: 1. Serious Health Condition of the Employee or Family Member 2. Parental Leave 3. Sick Child leave 4. Bereavement Leave Please read this statement
More informationHenry County Schools Family and Medical Leave Act (FMLA)
Henry County Schools Family and Medical Leave Act (FMLA) Please read carefully The Family and Medical Leave Act of 1993 requires the Henry County Schools to provide up to sixty (60) days of unpaid, job-protected
More informationThe employee s guide to. The Family and Medical Leave Act. Wage and Hour division UniTed STATeS department of LAbor
The employee s guide to The Family and Medical Leave Act Wage and Hour division UniTed STATeS department of LAbor An introduction to the Family and Medical Leave Act When you or a loved one experiences
More informationScope, Effects and Causes of Work-Related Stress
Scope, Effects and Causes of Work-Related Stress Work-related stress can be defined as the adverse reaction that people have to excessive pressure or other demands placed on them at work. Though not a
More informationCOMPLYING WITH THE FMLA AND ADA WHEN YOUR EMPLOYEE IS DEALING WITH A MENTAL HEALTH CONDITION
COMPLYING WITH THE FMLA AND ADA WHEN YOUR EMPLOYEE IS DEALING WITH A MENTAL HEALTH CONDITION Prepared for the Illinois Chamber of Commerce June 20, 2018 Scott Cruz The Plan The Big Picture: Mental Conditions
More informationOffice of Human Resources
Office of Human Resources IT Security Specialist CI2796 General Statement of Duties Performs full performance professional information security work enforcing information security practices and protocols;
More information