Nikesh K. Patel, MD
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509 Stillwells Corner Road, Suite E5 Freehold, New Jersey 07728 (732) 354-3792
Please complete Medical History Form to the best of your ability Name ___________________________________________________ Age _____ Height _______ Weight ___________ Purpose of Consultation __________________________________________________________________________________________________ How did you hear about Dr. Patel? ____________________________________________________________________ Please circle all of the following medical conditions that you have or have had in the past: Bleeding tendency hepatitis diabetes blood transfusion glaucoma dry eyes lung disease TB asthma wheezing emphysema bronchitis irregular heartbeat chest pain heart disease heart attack stroke epilepsy heartburn intestinal ulcers or bleeding depression mental illness drug or alcohol addiction any other serious injury or illness Please list any medications or herbal products that you take on a regular or occasional basis. If you can, please also include dosage and frequency: __________________________________________________________________________________________________ __________________________________________________________________________________________________ Please circle any medications that you are currently taking: Birth control pills aspirin ibuprofen containing drugs diet pills diabetic medications steroids glaucoma drops asthma medications Lanoxin nitroglycerin Isordil Inderal other heart medications Lasix other diuretics high blood pressure medications Coumadin Plavix tranquilizers sleeping pills antidepressants other pills or shots Do you have any allergies to medications? ____________ If so, please list drug and reaction: _____________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ Has anyone in your family or you ever suffered from diabetes, high blood pressure, breast cancer or odd reactions to anesthesia. Please list: __________________________________________________________________________________________________ __________________________________________________________________________________________________ Smoking can complicate surgery: Do you or have you ever smoked?________ If so, how much and for how long? _________________________________ Please list all previous surgeries that you have had : __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ Patient Signature: _______________________________________ Date: _________________ rev. 8/08
Student Health Information _____________ _____________ _____________ Family Doctor’s Name ____________________________________________________________________________ City ___________________________________ Phone _______________________________________ Dentist’s Name ________________________________ Date of last visit ________________________________ Optometrist’s Name ________
European Paediatric Neurology Society Board Meeting in Paris Faculté de Médecine Paris Sud, Bicetre Hospital, Friday, March 14 – Saturday, March 15, 2008 Attending: Marc Tardieu (MT), Paul Casaer (PC), Peter Baxter (PB), Willem Arts (WA), Bernhard Schmitt (BS), Lieven Lagae (LL), Hrissanthi Ikonomidou (HI), Oebele Brouwer (OB), Colin Kennedy (CK), Richard Newton (RN), Helen Cro