MEDICAL HISTORY Today’s Date:______________ Name:________________________________________________________ Date of Birth:_____/______/__________ Height:_________________ Weight:________________ Primary Care Provider: ____________________________________ Reason for your visit today: ________________________________________________________________________________ Duration:__________________________ Location:_____________________________ Any Pets?: □ No □ Yes Symptoms: _____________________________________________________________________________________________ Has this condition changed over time? □ No □ Yes If yes, how? _______________________________________________ Any past treatment? □ No □ Yes If yes, what treatment/medication?___________________________________ Any response to treatment? □ No □ Yes If yes, what? ______________________________________________________ Are you al ergic to any medications? □ No □ Yes If yes, list: 1.___________________________________ 2.________________________________ 3._______________________________ Reaction to allergy:
1.___________________________________ 2.________________________________ 3._______________________________ List al medications you are currently taking and dosage (follow-up patients: if any new medications, please list):
1.___________________________________ 2.________________________________ 3._______________________________ 4.___________________________________ 5.________________________________ 6._______________________________ Do you now, or have you ever had any of the fol owing diseases or conditions? (Please check if self or family member) List any surgeries you have had: _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ Do you drink alcohol? □ No □ Yes If yes, ___________drinks per day Do you bleed easily? □ No □ Yes Do you smoke?
□ No □ Yes If yes, ___________packs per day For how many years? ___________________ Have you been exposed to HIV? □ No □ Yes Women, are you pregnant or nursing? □ No □ Yes Have you ever had dental anesthesia (Xylocaine)? □ No □ Yes Any bad reaction? □ No □ Yes When exposed to sun, do you: □ Tan Only □ Tan and Burn □ Burn Do you, or have you ever used a tanning bed? □ No □ Yes Do you have a history of any specific skin diseases? □ No □ Yes If yes, please list: _________________________________ Preferred Pharmacy and location: _________________________________ Phone: ___________________________________ Patient/Guardian Signature_______________________________ Provider’s Signature: _______________________________
‘How to…. Apply Dovobet® Ointment’ Dovobet® is used in the management of psoriasis. It is a Vitamin D analogue called Calcipotriol plus a corticosteroid called Betamethasone. Vitamin D analogues may cause a little irritation to the skin around your psoriasis. Should a severe reaction occur i.e. intense itching, burning or dermatitis (eczema) then you should stop using the cream or o
Testimonial by Dr Anil Kumar (Swami Shantananda) M.D., D.C.H. Kriyayoga Research Institute, Jhunsi, Allahabad, U.P., India I , a U.S. citizen and a medical doctor, has specialized in the care of children and young adults for the last 38 years. After practicing modern medicine mostly in the United States of America and also in England and India, I have returned to India
MEDICAL HISTORY Today’s Date:______________