Diagnostic studies. 19 15.1.1.5 Reports on interviews with Xxxxxx Youth/NMD;
Diagnostic studies. PLEASE LIST THE APPROXIMATE DATE OF TEST, THE NAME OF THE FACILITY WHERE THE TEST WAS PERFORMED, THE NAME OF THE ORDERING PHYSICIAN AND THE RESULTS, IF KNOWN. TEST DATE FACILITY PHYSICIAN RESULTS X-RAY CT SCAN MRI EMG SPI 08/07 0000 Xxxxxxxxx Xxxx XX Xxxxxxx, XX 00000 Patient Name : Account #: MR # : Date : REVIEW OF SYSTEMS Please check any symptoms below that you currently have: HEAD Headaches Trouble with hearing Trouble with eyesight Nasal discharge Hay Fever, frequent sneezing Sinus trouble, post nasal drip THROAT Hoarseness Ulcer of tongue or mouth Trouble with gums or teeth Sore throat LUNGS Asthma, wheezing Cough Cough up blood Tuberculosis Shortness of breath CARDIOVASCULAR High blood pressure Chest pain Irregular beat or palpitation of heart ENDOCRINE Increased thirst, hunger Sudden weight change Sensitive to heat/cold Change in skin, body hair Change in sex drive SKIN Rash Tumor on skin BLADDER AND KIDNEY Frequency urgency or pain with urination Passed blood or kidney stone Trouble starting or stopping of urinary stream STOMACH AND BOWELS Trouble swallowing Abdominal pain, nausea, vomiting Acid Reflux (“Heartburn”) Stomach ulcer/Duodenal ulcer Black bowel movements Diarrhea Constipation Hemorrhoids or rectal itching MUSCULAR Low back pain Joint pain Arthritis Neck pain NERVOUS Backache Balance prolems Numbness or tingling anywhere Weakness Trouble walking MISCELLANEOUS Problems with sleep Dizziness Depression Fatigue Anemia or difficulty with bleeding Sexual problems OTHER? (Please describe) Awaken at night with shortness of breath PROBLEM LIST Please check any of the following below that you have had or currently have a problem with: Alcohol Acquired Brain Injury ALS Asthma Bladder Pain / Spasms Blood Clots Blood in Stool Blood in Urine Cerebral Palsy Cigarettes Current Pregnancy Diabetes Drugs Dysreflexia Frequent UTI Gynecological Problems Hay Fever / Allergies High Blood Pressure HIV (or AIDS) Impaction Kidney Failure Multiple Sclerosis Neurogenic Bladder Neurogenic Bowel Paraplegia Pneumonia Post Polio Psychiatric Problems Respiratory Failure Quadriplegia / Tetraplegia Seizures Skin Problem Xxxxx Bifida Spinal Problems Stroke Ventilator Use SPI 08/07 0000 Xxxxxxxxx Xxxx XX Xxxxxxx, XX 00000 Date Patient Name Medical Record Number YES NO Please fill out this form by checking the appropriate boxes and sign where indicated.
Diagnostic studies. 17 16.3.24 Report of interviews with YOUNfi ADULT.
Diagnostic studies. 28 9.1.1.5 Reports on interviews with Youth/NMD; 3 4 5 professionals; medical/dental visits and
Diagnostic studies. 1. Carrying out of a comprehensive diagnostic study aimed at assessing all the current arrangements covering the financial, operational, technical, legal and contractual aspects pertaining to the exploitation of oil resources and the management of oil revenues with a view to designing a comprehensive reform program aimed at improving the management of the Borrower’s petroleum sector.
Diagnostic studies. 13 7.1.4 Reports on interviews with xxxxxx child;
