CONFIDENTIAL PATIENT CASE HISTORY As a multidisciplinary practice providing comprehensive care, we focus on your ability to be healthy. Our goals are: firstly, to address the issues that brought you to this practice; secondly, to treat the cause of your condition (not just treat the symptoms or place a temporary patch over your condition); and thirdly, to offer you the opportunity of improved health potential and wellness services in the future. Answering the following questions will give us a profile of your health, and ensure that we optimise your outcome and deliver treatment excellence. What is your major complaint? _________________________________________________________________ Draw on the sketch below the area(s) where you feel your problem to be.
When did your symptoms start? _________________________________________________________________ Was it a gradual or sudden onset? _________________________________________________________________ Have you had this or a similar problem in the past? _________________________________________________________________ If you are experiencing pain, please tick the words that best describe your pain:
Confidential Patient Case History Form Version 1.0,
Do you get?
needles Since the problem started it is:
About the same Getting better Getting worse
What makes your pain worse? Your pain interferes with: What type of work do you do? __________________________________________________________ Any Bladder or Bowel changes since this episode started? __________________________________________________________ Do you experience any nausea, dizziness, difficulty swallowing, changes in vision, or fainting spells, fever, skin rashes associated with your symptoms? __________________________________________________________ Other health professionals seen for this problem (please list): Medical Doctor____________________________________________________________ Specialist Doctor/Surgeon_____________________________________________________ Physiotherapist/Chiropractor __________________________________________________________________ Other __________________________________________________________________ List any medications you are taking __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ Have you ever taken oral cortisone or prednisone (including asthma medications such as pulmicort, symbicort, flixotide & seretide)? Y/N Are you pregnant? Y/N
Confidential Patient Case History Form Version 1.0,
Do you have or have you ever had?: (please tick)
High blood pressure
Patient’s Signature: _______________ Print Name: ______________________ Practitioner's Signature: _________________ Date: _____________________
Confidential Patient Case History Form Version 1.0,
Max GXL Ingredients Serving Size – 3 capsules (56 servings per box) – take 1 pkg in the am, one in the pm – comments next to the ingredients are those of a friend who likes to analyze this Amount per serving Vitamin C (as Calcium Ascorbate) – 250mg N-Acetyl Cysteine – 375mg L-glutamine – 750mg N-Acetyl D-Glucosamine – 125mg Quercetin – 37.5mg
Joseane AmesI,II Falsifi cação de medicamentos Daniele Zago SouzaIII no Brasil Counterfeiting of drugs in Brazil OBJETIVO: Identifi car os principais medicamentos falsifi cados apreendidos pela Polícia Federal brasileira e os estados em que houve a apreensão. MÉTODOS: Estudo retrospectivo descritivo dos laudos periciais elaborados por Peritos Criminais da Polícia Feder
CONFIDENTIAL PATIENT CASE HISTORY 
Do you have or have you ever had?: (please tick)