C73 C74 C75 C82 C83 C84
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- Donna Wilcox
- 5 years ago
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1 C Var lab. C9 Headache, migraine / C10 Cold, flu / C11 Cough / C12 Long bronchitis / C13 Poor eyesight, eye disease despite glasses / C14 Impaired hearing / C15 Menstrual discomfort/ C16 Other lower abdominal discomfort (discharge, pain) / C17 Gastric catarrh or gastric ulcer / C18 Other stomach pain C19 Nausea C20 Loss of weight / C21 Diarré C22 Constipation / C23 Bad appetite / C24 Obesity / C25 Shoulder pain / C26 Aching hand, elbow, knees, legs / C27 Back ache, hip ache or sciatica / C28 Inflammation of the bladder, catarrh / C29 Asthma / C30 Sports injury / C31 Accident injury / C32 Diabetes / C33 Epilepsy / C34 Struma / C35 Fatigue / C36 Breathlessness / C37 Dizziness / C38 Overstrain / C39 eczema / C40 Rash, psoriasis / C41 Blood loss, anaemia / C42 Allergic / C43 Allergy against what? / C44 Other disease / C45 Pain-killer, analgesic / C46 Gastric catarrh medicine / C47 Other medicine / C48 Difficulty sleeping / C49 Sleeping-pill / C50 Restless / C51 Concentration difficulty /
2 C52 Worried / C53 palpitation / C54 Anxiety / C55 Other / C56 Nervous troubles / C57 How often sad / C58 Why sad / C59 Used medication / C60 Been to psychologist / C61 Concentration / C62 Difficulty sleeping / C63 Been useful / C64 Make decisions / C65 Felt pressured / C66 Difficulties to solve problems / C67 Appreciate what I do / C68 Dealt with problems / C69 Felt unhappy / C70 Stopped believing in yourself / C71 Felt worthless / C72 Felt happy / C73 C74 C75 C76 Unable to do things / C77 Height / C78 Weight / C79 Age at first menstruation years / C80 Age at first menstruation months / C81 Unable to work / C82 C83 C84 C85 Drink beer / C86 Amount medium-strong beer / C87 How often beer / C88 Amount strong beer / C89 How often wine / C90 Amount wine / C91 How often strong spirits / C92 Amount strong spirits / C93 Smoke cigarette / C94 Smoke pipe tobacco / C95 Use moist snuff / C96 Friends who use drugs /
3 C97 Use hashish / C98 Other drugs / C99 Coffee / C100 Milk / C101 Egg / C102 Fruit juice / C103 Porridge / C104 Dark breed / C105 Sweet bread / C106 Other / C107 Drink coffee / C108 Eat sweets / C109 Salt / C110 Reflector tape / C111 Been reported to the police / C112 Brush teeth / C113 Visited dentist / C114 Often shower / C115 Contraceptive / C116 sports / C117 Rather live short and enjoy / C118 Hours sleep / C119 What do now / C120 C121 C122 C123 Prefered working hours / C124 Do what you would prefer / C125 C126 C127 What is preventing you / C128 C129 Find work through job centre / C130 Find work through friends / C131 Find work by myself / C132 Education / C133 C134 C135 C136 Summer 1983 /
4 C137 C138 C139 C140 C141 Summer 1984 / C142 C143 C144 C145 C146 C147 C148 C149 C150 C151 C152 C153 C154 Number of times unemployed / C155 Unemployed months / C156 Unemployed weeks / C157 Unemployment effect on finances / C158 Unemployment effect on family / C159 Unemployment effect on friends / C160 Unemployment effect on leisure / C161 Unemployment effect on health / C162 Unemployment effect on mood / C163 Number youth introduction program / C164 Program months / C165 Program weeks / C166 Number youth law / C167 Youth law months / C168 Youth law weeks / C169 Youth law 8 hours months / C170 Youth law 8 hours weeks / C171 C172 C173 Why stopped / C174 Number public relief work / C175 Public relief work months / C176 Public relief work weeks / C177 Number AMI-AMU / C178 AMI-AMU months / C179 AMI-AMU weeks /
5 C180 Number temp employment / C181 Temp employment months / C182 Temp employment weeks / C183 Working hours in temp employment / C184 Number perm employment / C185 Perm employment months C186 Perm employment weeks / C187 Working hours in perm employment / C188 Quit education / C189 Give notice / C190 C191 C192 Hurry / C193 Monotonous / C194 Learning / C195 Decide yourself / C196 A lot to do / C197 Can use your interests / C198 Get on quite well / C199 Like my friends / C200 Important to work/ C201 Even if I won money / C202 Hate unemployment / C203 Get bored fast / C204 Most important to work / C205 Prefer work to benefits / C206 Busy all the time / C207 Don t need to be punctual / C208 Regular hours / C209 Other look down on me / C210 Do important things / C211 Moved, since months / C212 C213 C214 Reason for moving / C215 Want to move back / C216 Live together with / C217 How many times moved / C218 How many children / C219 C220 C221
6 C222 Income / C223 Able to get 5000kr / C224 Seriously ill / C225 Died / C226 Discord / C227 Divorced parents / C228 Unemployment / C229 Social group / C230 Watch TV / C231 By your self / C232 Meaningful leisure time / C233 Videos / C234 Interesting job / C235 Go steady / C236 Make a lot of money / C237 Nice clothes / C238 Books / C239 Children / C240 Car / C241 Computer games / C242 Take responsibility / C243 Unemployed friends / C244 Association activities / C245 In six months / C246 C247 C248 Get desired job / C249 Own fault if unemployed / C250 Too few jobs / C251 Try change unemployment / C252 Move / C years work / C years education / C years unemployed / C years early retirement pension / C years seriously ill / C years very healthy / C years alcohol problem / C years poor / C years rich / C years successful / C years move south / C years move back / C years live alone / C years married / C years divorced / C years children / C years active /
7 C years other / C271 Pers index / C272 Pers index / C273 Pers index / C274 Pers index / C275 Pers index / C276 Pers index / C277 Pers index / C278 Pers index / C279 Pers index / C280 Pers index / C281 Pers index / C282 Pers index / C283 Pers index / C274 Pers index / C275 Pers index / C276 Pers index / C277 Pers index / C278 Pers index / C279 Pers index / C280 Pers index / C281 Pers index / C282 Pers index / C283 Pers index / C284 Pers index / C285 Pers index / C286 Pers index / C287 Pers index / C288 Pers index / C289 Pers index / C290 Pers index / C291 Pers index / C292 Pers index / C293 Pers index / C294 Pers index / C295 Pers index / C296 Pers index / C297 Pers index / C298 Pers index / C299 Pers index / C300 Pers index / C301 Pers index / C302 Pers index / C303 Pers index / C304 Pers index / C305 Pers index / C306 Pers index / C307 Pers index / C308 Pers index /
8 C309 Pers index / C310 Pers index / C311 Pers index / C312 Pers index / C313 Pers index / C314 Pers index / C315 Pers index / C316 Pers index / C317 Pers index / C318 Pers index / C319 Pers index / C320 Pers index / C321 Pers index / C322 Pers index / C323 Pers index /
9 Val lab. C9 C10 C11 C12 C13 C14 C15 C16 C17 C18 C19 C20 C21 C22 C23 C24 C25 C26 C28 C29 C30 C31 C32 C33 C34 C35 C36 C37 C38 C39 C40 C41 C42 1 No 2 Yes a bit 3 Yes a lot C44 C45 C46 C47 1 No 2 Yes C48 C49 C56 C57 1 Never 2 Sometimes 3 Often 4 Constantly C59 1 Never 2 Once 3 A few times 4 Many times C60 1 No 2 Yes C61 C62 C63 C64 C65 C66 C67 C68 C69 C70 C71 C72 1 Not at all 2 As usual 3 A bit more than usual 4 A lot more than usual C81 1 No 2 Yes C85 1 don t drink 2 Every other day 3 Once or twice a week 4 Few times per month 5 Rarely C86 C88 1 Don t drink 2 A bottle or less 3 One can 4 Two cans 5 Three to four cans 6 Five cans or more C87 C89 C91 1 Don t drink 2 Every other day 3 Once or twice a week 4 Few times per week 5 Few times per month 6 Rarely C90 1 Don t drink 2 2-5cl cl 4 Half a bottle 5 60cl or more C92 1 Don t drink 2 2cl 3 4-6cl cl 5 18cl 6 37cl or more C93 1 No never 2 No quit 3 yes C93a Less one cigarette a day C93b 1-10 cigarettes a day C93c cigarettes a day C94d More than 20 cigarettes a day C95 1 No never 2 No quit 3 Yes
10 C95a Five times a day or more C95b 3-4 times a day C95c Few times a week C95d Few times per month or less C96 1 No 2 Yes C97 C98 1 Never 2 Once times times times 6 More than 20 times No 2 Yes Several times per day 2 Few times per day 3 Several times a week 4 Few times per week 5 More seldom than a few times per week C109 1 Very often 2 Often 3 Sometimes 4 Seldom 5 Never C110 1 Always 2 Often 3 Sometimes 4 Seldom 5 Never C111 1 No 2 Yes C112 1 Seldom/never 2 Few times per week 3 Several times per week 4 Once a day 5 Several times per day C113 1 Less than a year ago 2 Less than two years ago 3 Some time after year 9 4 In primary school year C114 1 Every day 2 Several times per week 3 Few times per week 4 Few times every other week 5 Few times per month 6 More seldom C115 1 No, want children 2 Yes every sexual intercourse 3 Didn t use once 4 Didn t use a few times 5 Didn t use several times 6 Never use 7 Never had sexual intercourse C116 1 Daily 2 Several times a week 3 Few times per week 4 Several times per month 5 Few times per month 6 Seldom/never C117 1 Agree completely 2 Agree partly 3 Don t know 4 Don t agree 5 Do not agree at all
11 C129 C130 C131 1 To a considerable part 2 To quite a large part 3 To quite a small part 4 Not at all C157 C158 C159 C160 C161 C162 1 Deterioration 2 No change 3 Improvement C173 1 Got permanent employment 2 Got temporary employment 3 Started an education 4 Had to leave because I turned 20 5 I was given notice C188 1 No 2 Yes, once 3 Yes several times 3a Changed program 3b Got an empoyment 3c Didn t like it 3d Other. What? C189 1 No 2 Yes, once 3 Yes, several times 3a Got a better job 3b Didn t like it 3c Other. What? C192 C193 1 Yes 2 No C194 1 Yes, a lot 2 Yes, a bit 3 Neither a lot nor a little 4 No, not much 5 No, very little C195 1 Yes, very often 2 Yes, often 3 Neither often nor seldom 4 Seldom 5 Very rarely C196 1 Yes, far too much 2 Yes, too much 3 Neither too much nor too little 4 No, too little 5 No, far too little C197 C198 C199 1 Very well 2 Good 3 Neither good nor bad 4 Poorly 5 Very poorly C200 C201 C202 C203 C204 C205 C206 C207 C208 C209 C210 0 Do not agree at all 3 Not sure 6 Agree completely C214 1 Parents moved 2 To study 3 To work 4 To have a look around 5 Other reasons C215 1 Yes, as soon as possibile 2 Yes, in a few years 3 It doesn t matter 4 No, I don t think so 5 No, definitely not C216 1 Mom and dad 2 Mom 3 Dad 4 Partner 5 Alone 6 Friends 7 Other. What? C218 1 Yes 2 No
12 C223 1 No 2 Yes, my own assets 3 Yes, loan 4 Yes, through other means C224 C225 C226 C227 C228 1 Yes 2 No C230 1 Several shows per day 2 A few shows per day 3 A few shows every other evening 4 Less than one show per week C231 1 Almost always with friends 2 Most of the time with friends 3 As much with friends as by my self 4 Most by my self 5 Almost always by my self C232 1 Yes, very much 2 Yes, a bit 3 Neither yes nor no 4 No, not a lot 5 No, not at all C233 C234 C235 C236 C237 C238 C239 C240 C241 C242 1 Very necessary 2 Quite necessary 3 Neither nor 4 Quite unnecessary 5 Very unnecessary C243 1 Yes, most of them 2 Yes, a few 3 No, none C244 1 Several times per week 2 A few times per week 3 Few times every other week 4 Few times per month 5 Seldom or never C245 1 University 2 Other education 3 Permanent empoyment 4 Temporary employment 5 Unemployed 6 Other. What? 7 Don t know C248 1 Yes 2 Don t know 3 No C249 C250 1 Agree completely 2 Partly agree 3 Do not agree at all C251 1 Yes, through organizations 2 Yes, through a different way. How? 3 No, its no use 4 The most imoportant is my own job 5 Don t know C252 1 I am not moving 2 Could move to get a job 3 Doesn t matter if I move 4 I want to move south 5 Don t know 6 I have allready moved
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Riverview Orthopedics and Sports Medicine 493 Westfield Rd
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Aurora Family Medicine Center, P.C.
Patient Name(Please print): D.O.B. Patient Address: Home Phone: City, State, Zip Family Members Sex D.O.B. Relationship Primary Dr. NAME OF PRIMARY INS. COMPANY and POLICY HOLDER Other Insurance Coverage?
PEDIATRIC REGISTRATION FORM
PEDIATRIC REGISTRATION FORM **Today s Date: PATIENT INFORMATION: (Please use full legal name, no nicknames) *Last Name: *First Name: Middle Initial: *Address: City: State: Zip: *Sex: *Date of Birth: Age:
Name Date of Birth / / First M.I. Last. Address City State Zip. Home Phone Cell Phone Work Phone. Address
3055 SOUTHWESTERN BLVD. 3500 SHERIDAN DR. ORCHARD PARK, NY 14227 AMHERST, NY 14226 (716) 675 2500 (716) 204 4263 PATIENT INFORMATION (Please Print) Today s Date: / / Name Date of Birth / / First M.I. Last
PATIENT REGISTRATION
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IF WE NEED TO CONTACT YOU ASAP FOR SCHEDULE CHANGES, WHAT NUMBER SHOULD
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19455 Deerfield Avenue Suite 312 Lansdowne, Virginia Stone Spring Blvd, Suite 345 Dulles, VA 20166
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PATIENT INFORMATION PATIENT NAME Last First M.I. Social Security Number
PATIENT INFORMATION PATIENT NAME Last First M.I. Social Security Number ADDRESS Street DATE OF BIRTH SEX Female Male City State Zip Home Phone Cell Phone Work Phone EMAIL Marital Status Single Widowed
Patient Information Last Name First Name Middle Initial
Patient Information Last Name First Name Middle Initial Street Address Apt# City State Zip Code Social Security # Home Phone Cell Phone Email D.O.B Sex(M/F) Occupation Relation to Insured Self Spouse Child
PERSONAL INFORMATION
Thank you for selecting our team for your dental care. We are pleased to welcome you to our practice! To help us better serve you and meet your dental healthcare needs, please complete the following forms.
Patient Registration. D. INSURANCE (if applicable)
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Brighter Smiles Family Dentistry
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Anthony Sparano, M.D.
Anthony Sparano, M.D. Facial Plastic Surgeon Sparano Face & Nasal Institute NJ Institute for Robotic Hair Surgery Skin Sense Spa Patient : DOB: Date: Home Phone: ( ) Mobile Phone: ( ) E mail Address: Please
Wayne Foot & Ankle Center, P.A.
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PATIENT INFORMATION. Patient s Full Name: (First) (Middle) (Last)
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Hun Chiropractic 1 Creekview Ct, Suite B Greenville, SC P: F:
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Welcome. Patient Name: Social Security #: (Last name) (First name) (Middle Initial) Street Address City State Zip
Welcome Thank you for choosing us for your dental care needs. We promise to do our best to provide you with the finest care available. If you have any questions, please do not hesitate to contact us. (206)
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Patient Information. Major Medical Worker's Compensation Medicaid Medicare Auto Accident Medical Savings Account & Flex Plans Other
Patient Information Date: Name: Birth Date: Age: Marital: M S W D Address: City: State: Zip: E-mail address: Phone: Occupation: Employer: Spouse: Occupation: Employer: How many children? Names and ages
Your Health Profile. Childhood Years. Adult Years
Name: Age: Date: Height: Address: City: State: Zip Code: Home Address if Student: City: State: Zip Code: Cell Phone: ( ) Home Phone: ( ) Male: Female: Reason for consulting our office? Wellness Evaluation:
PATIENT INFORMATION FORM RICHARD L. MALINICK, M.D. ORTHOPAEDIC SURGERY 1125 Via Verde, San Dimas, CA
Email Address Last Name First Name Previous Name Address City State Zip Country Social Security - - Home Phone - - Cell Phone - - Work Phone - - Ext Drivers License State Responsible Party SELF (use info
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Babylon Medical Practice
Today s Date: / / Last Name: Page 1 Babylon Medical Practice 350 West Main Street, Babylon, NY 11702 350 West Main Street Babylon, NY 11702 Tel Telephone: lephone: (631) (631) 661-22 661-2277 277 Fax:
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Child s Legal Name: Today s Date: / / Address: City: ST: Zip: Home Phone: Parent s Cell Phone: Date of Birth: / / Age: Gender: M F Social Security #: Mother s Name: Father s Name: Sibling s Name(s) and
Southern Dermatology Dr. W. Derrick Moody 1805 Herrington Road 3A, Lawrenceville, GA 30043
Patient Information: Name:!!!! Last!!!! First!! Initial! Sex: Date of Birth: Age: SSN: Phone Numbers:!!!!!! Home!!! Work!!!! Cell Patient Address:! Street Address!!! City!!! State Zip Code Race: Black/African
We look forward to meeting you, and will be available for you at any time. Dr. Douglas Scott, M.D. Dr. Kirk Johnson, M.D.
Welcome to Orthopedic Associates of the Lowcountry. Thank you for your confidence in allowing us to help care for your health. It is a responsibility we respect, and take very seriously. Please take the
Yu s Acupuncture & Herb center
New Patient Information Questionnaire Patient Name Sex: M, F First MI Last Date of Birth / / Height Occupation: Weight Marital Status: Single, Married, Other Phone (Day) ( ) - Phone (Evening) ( ) - Phone
Welcome to Tyler L. Smith Family Dentistry
Today s : Patient Information Welcome to Tyler L. Smith Family Dentistry Last: First: Middle Initial: _ Preferred: Address: City: State: Zip: Home #: Email: Cell #: Work #: Sex: Birth : Social Security