Le métronidazole (Flagyl) reste la référence dans le traitement des infections anaérobies et des parasitoses comme la giardiase ou l’amibiase. Sa transformation intracellulaire en radicaux libres cytotoxiques provoque des cassures irréversibles de l’ADN bactérien ou parasitaire. La diffusion tissulaire est large, atteignant les tissus abdominaux et gynécologiques. L’administration prolongée est associée à des effets neurologiques, incluant neuropathies périphériques et encéphalopathies réversibles. L’association avec l’alcool déclenche une réaction de type antabuse. Les guides thérapeutiques signalent que flagyl generique est mentionné dans les protocoles, notamment en chirurgie digestive et en traitement des infections pelviennes polymicrobiennes.

Collierville alzheimer’s day care center

Page Robbins Adult Day Care Center
Physician’s Form
(Note to Physician: The client and their caregiver below are completing an application for admission to Page
Robbins Adult Day Care Center. We provide day services to adults with dementia and/or who are frail. Please
complete this 3 page form and mail/fax it to our center or give to the primary caregiver. Thank you.)
General Information

______________________________________________ Street Address ______________________________________________ City and State ______________________________________________ Responsible Party/ Legal Guardian __________________________ Phone_______________ Height ______ Drug/Allergies _____________________________ Latex Allergy?______ (Please note that a chest XRay OR a Skin Test must have been completed within the last 6 months.)
Chest X-Ray: Yes_____No_____Date:________Results:_________________
PPD Skin Test: Yes_____No_____Date:________Results:_________________
Identification and Background Information

Last Medical Assessment Date ________________by______________________________
Bowel and Bladder:
Client has complete control of bowel and bladder
If No, Please Explain: _________________________________________________________ Client has one of the following: 1. External Catheter ______ 2. In-dwelling Catheter ______ 3. Pads, Briefs ______ 4. Ostomy (Please Specify) ______ 5. None ______ 6. Other ______ Client has been tested for a Urinary Tract Infection in the last 60 days Yes______No______ If Yes, Medication Prescribed: __________________________________________________ Page Robbins Adult Day Care Center Medical Form
Disease Diagnosis (Please check if yes)

Heart/Circulation
Arteriosclerotic Heart Disease
Other Cardiovascular Disease:________________
Neurological
Alzheimer’s disease
Other (Please specify) __________________________________________________________________
Pulmonary
Emphysema
Other: (Please specify) _________________________________________________________________
Psychiatric/Mood
Anxiety Disorder
Other: (Please specify): ________________________________________________________________
Vision

Other:
Anemia
7. Past Surgical History: ____________________________________________________________________ 8. Other Health Conditions: _________________________________________________________________ Page Robbins Adult Day Care Center Medical Form
Existing Conditions:
Constipation

Ambulation:
Independent
Please specify: ___________________________
Current Medications
(Please include: Name, Dosage, Frequency and Reason for Medication)
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
Non-Prescription Drugs (Given at the center PRN according to label if symptoms occur)
Tylenol 500 mg, 1 tab every 3-4hours

I certify that _____________________________________is free from Communicable Disease
Client’s Name)
and able to participate in an Adult Day Care Program.
_______________________________________ ___________________________
Physician (Please sign and Print Name) Date
_______________________________________
Physician Address Physician Phone Number Page Robbins Adult Day Care Center Medical Form

Source: http://pagerobbins.org/wp-content/uploads/Current-Physicians-Statement-Form-april-2011.pdf