Page 1 of 5 Patient Past Medical, Social & Family History INSTRUCTIONS: Complete the following information by placing a check mark (√) in the appropriate boxes or by PRINTING the requested information. DO NOT write in the shaded areas labeled “For
Maintain the log on file for five years. These sample logs are intended to provide your office practice with a methodology to track the sample medications that you dispense as well as aid you in identifying those that have expired and require disposal. The Can you name all of the medications you are taking? Do you know what doses you are taking and what the medicine is for? “My Medicine List ” can help you keep track of everything you take to keep you healthy, including pills, vitamins, and herbs. Having a list of Below you will find a compressed zip data file of the FDA Acronyms & Abbreviations database. All fields are separated by tabs in the text file. Its use is only recommended for those who wish to import this information into a database or spreadsheet. It will be updated quarterly. The data is one Mammogram (breast xray) Pap smear (for women) Colonoscopy Blood work X-rays ECG / EKG (heart) Vision DEXA (checks for bone loss, or osteoporosis) MRI CT (“CAT” scan) other _____ List where and when you had the tests Blue, Red, or Green Graph Paper Grids All of the above graph paper templates for Word are theme-enabled.docx files, meaning that you can change the color of the grid by going to Page Layout > Themes > Colors. I've saved these all using a custom medium gray
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Health and Medical Templates in OpenOffice format If you don't see an OpenOffice Template design or category that you want, please take a moment to let us know what you are looking for. Make a suggestion My Medications List Helps you keep track of your medicines, total your medication costs by month, quarter and year along with having plenty of room for jotting down important notes about each of your medications such as "No Alcohol", "Take with. Maintain the log on file for five years. These sample logs are intended to provide your office practice with a methodology to track the sample medications that you dispense as well as aid you in identifying those that have expired and require disposal. The Can you name all of the medications you are taking? Do you know what doses you are taking and what the medicine is for? “My Medicine List ” can help you keep track of everything you take to keep you healthy, including pills, vitamins, and herbs. Having a list of Below you will find a compressed zip data file of the FDA Acronyms & Abbreviations database. All fields are separated by tabs in the text file. Its use is only recommended for those who wish to import this information into a database or spreadsheet. It will be updated quarterly. The data is one Mammogram (breast xray) Pap smear (for women) Colonoscopy Blood work X-rays ECG / EKG (heart) Vision DEXA (checks for bone loss, or osteoporosis) MRI CT (“CAT” scan) other _____ List where and when you had the tests Blue, Red, or Green Graph Paper Grids All of the above graph paper templates for Word are theme-enabled.docx files, meaning that you can change the color of the grid by going to Page Layout > Themes > Colors. I've saved these all using a custom medium gray
I understand that Merck PAP reserves the right to modify the application form, modify or without limitation allergies, medical conditions, or other medications being taken by me. I have read this document or have had it explained to me.
