Patient Name______________________________________________ Today’s Date____________________ Age:________________
Mail Order Pharmacy Name/Address: __________________________________________________________ Phone:____________________________________ Local Pharmacy Name/Address: ______________________________________________________________ Phone: ___________________________________
Allergies? (Circle) Yes (if yes, please list below) or No ______________________________________________________________________________________ ______________________________________________________________________________________ Medication List
Please list all medications: Prescription/over the counter/vitamins/supplements List dosage and how often you take Example: Flomax 0.4 mg 1 tablet a day Name
List all Surgery from childhood to present including year of surgery. Example: Tonsils removed 1989 1.______________________________________________________________________________________ 2.______________________________________________________________________________________ 3.______________________________________________________________________________________ 4.______________________________________________________________________________________ 5.______________________________________________________________________________________ 6.______________________________________________________________________________________ 7.______________________________________________________________________________________
Patient Name______________________________________________ Today’s Date____________________
SYMPTOMS: Check (√) symptoms you currently have or have had in the past year. CONSTITUTIONAL EARS, NOSE, MOUTH, CARDIOVASCULAR RESPIRATORY GASTROINTESTINAL GENITOURINARY MUSCULOSKELETAL INTEGUMENTARY/ NEUROLOGICAL HEMATOLOGIC/ LYMPHATIC □ Persistent Itching CONDITIONS: Check (√) conditions you have or have had in the past. □ AIDS □ Constipation
GOVERNMENT OF INDIA DIRECTORATE GENERAL OF SUPPLIES &DISPOSALS JEEVAN TARA BUILDING, SANSAD MARG, NEW DELHI - 110 001. Sub : Summary of Economic Intelligence Bulletin. Economic Intelligence Bulletin includes abstracts of important economic/commercial/ technical development and reviews as reported in the issues of financial dailies. The Bulletin pertains to the fortnight e
Disease Management ABOUT OUR FORMULARY FORMULARIES What is a formulary? “Open” Formulary A formulary is a listing of prescription medications that are preferred for use A plan that has adopted an “Open” formulary allows coverage for both by a plan and are dispensed through participating pharmacies to covered formulary and non-formulary drugs. Drug coverage is not d
Patient Name______________________________________________ Today’s Date____________________ Age:________________
Mail Order Pharmacy Name/Address: 
Patient Name______________________________________________ Today’s Date____________________
SYMPTOMS: Check (√) symptoms you currently have or have had in the past year.