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Newreflectionsps.com

Nikesh K. Patel, MD
axã exyÄxvà|ÉÇá cÄtáà|v fâÜzxÜç 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

Source: http://www.newreflectionsps.com/forms/Medical_History_Form.pdf

Microsoft word - health information form - deb will send out this year

Student Health Information _____________ _____________ _____________ Family Doctor’s Name ____________________________________________________________________________ City ___________________________________ Phone _______________________________________ Dentist’s Name ________________________________ Date of last visit ________________________________ Optometrist’s Name ________

Microsoft word - bm_paris_mar_08l.doc

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

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