NEW PATIENT INTAKE FORMS PEDIATRIC
AMY MYERS, MDAustin UltraHealthWestlake Medical Center5656 Bee Cave Road Suite D-203Austin, Texas 78746Phone: 512-383-5343Fax: 512-721-0348NEW PATIENTINTAKE FORMSPEDIATRICFor ages 0-13 yearsTHESE FORMS MUST BE SUBMITTED TO OUR OFFICEAT LEAST 7 DAYS PRIORTO YOUR FIRST APPOINTMENTDue to sensitivities, our office is fragrance free. We ask that you DO NOT wearscented products to our office. This includes perfumes, colognes, lotions,deodorants, soaps and shampoos.1
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
/S*0,*&T"(%#)0,*'()%"1#7/%#- 18%#/% -0 4D;5%%3A895%%0HH6577"%/? F% D 5%G? ""#I;D? %%&DJK%#8#,2#/1#69206:65;#/: 027 2#2?72#; @#5/12#2?6# ?70:7A;B1#C79# @:D60E#E"/H" ;37;&IJ HHA'/';5 18%#/% -0"4D;5%%3A895%%0HH6577"%/? F% D 5%G? ""#I;D? %%&DJK%#8#,2#/1#69206:65;#/: 027 2#2?72#; @#5/12#2?6# ?70:7A;B1#C79# @:D60E#"R"
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
,-.(&* "S(3')0T".(3-*3-3V".(*5%)3(3V"&)%.('()%3"/A5:O%D 68 6?D 5%P8J%D9H% 68Q?H5%HD 5%8M%8975 %/6EB"&?;;8 B""""""""":9JLMQK.LGJLK.9N ?PJEPNQJTGNGL9NI 19K. UE";5VW /6EB"&?;;8 B"(;; B6K78"\@O87"3L D;@98"QQQQQQQQQQQQQQQQQ"""""""( :76996B@;L"\@O87". E86E8"QQQQQQQQQQQQQQQ"/6EB"&?;;8 B"""&;@F ZE"QQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQ""""""""" 7 8;6B C8"&@7 B E"QQQQQQQQQQQQQQQQQQQQQQQQQ"""""*?B@ 99? 8". E86E8"QQQQQQQQQQQQQQQQQQQQQQ"""""56EB; B E"@;"/8AB " 7 8;". E86E8"QQQQQQQQQQQQ"""""0F8?96B@ D"*;BF; B QQQQQQQQQQQQQQQQQQQQ""""" ?A?E"3 -"QQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQ"""""&87 6 ". E86E8"QQQQQQQQQQQQQQQQQQQQQQQQQQQ"""""(99? 8".8: 8 L". QQQQQQQQQQQQQQQQQ"""""38C8;8"( :8 B @?E". E86E8"QQQQQQQQQQQQQQQQQQQ"/6EB"&?;;8 B"""""/@@;"(99? 8"#? B @ "QQQQQQQQQQQQQQQQQQQQ"""""E9M4KQX9JEPN9M S86;B". E86E8"QQQQQQQQQQQQQQQQQQQQQQQQQQQQ"""""N:;8]?8 B" :8 B @ """"#@@D"*778;M 8E"QQQQQQQQQQQQQQQQQQQQQQQQQQQQ"""""SLA8;B8 E @ "NF MF"K7@@D"A;8EE?;8P"QQQQQQQQQ"""""- C ;@ 98 B67"*778;M 8E"QQQQQQQQQQQQQQQQQQQ"""""0F8?96B "#8C8;"QQQQQQQQQQQQQQQQQQQQQQQQQ""""",?7B A78"&F89 67"38 E B C B 8E"QQQQQQQQQQQQQQ""""", B;67" 67C8"/;@76AE8"QQQQQQQQQQQQQQQQQQQQQ""""" QQQQQQQQQQQQQQQQQQQQQQQQQ"""""/6EB"&?;;8 K.!N9?9LKQ.I 9PLQK?P.G &F;@ "#6B M?8"3L D;@98"QQQQQQQQQQQQQQQQQ"""""/6EB"&?;;8 B"'LA8"!". 6K8B8E"QQQQQQQQQQQQQQQQQQQQQQQQQQ"""""""'LA8"4". 6K8B8E"QQQQQQQQQQQQQQQQQQQQQQQQQQ"""""#;8]?8 B" AA8;"08EA ;6B@;L"( :8 B @ E"QQQQQQQ"""""SLA@M7L 89 QQQQQQQQQQQQQQQQQQQQQQQQQ""""",8B6K@7 "3L D;@98"N/;8 . 6K8B8EP"QQQQQQQQ"""""&F;@ "3 ?E B E"QQQQQQQQQQQQQQQQQQQQQQQQQQ"""""SLA@BFL;@ D E9"N7@O"BFL;@ DP"QQQQQQQQQQQQQ"""""\;@ F B E"QQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQ"""""SLA8;BFL;@ D E9"N@C8;6 B C8"BFL;@ DP"QQQQQQQ"""""3788A"*A 86"QQQQQQQQQQQQQQQQQQQQQQQQQQQQQQ"""""- D@ ; QQQQQQQQQQQQQQQQQQQQQQQQQQQQQ"""""/@7L LEB ")C6; 6 "3L D;@9"N/&)3P"QQQQQQQQ"/6EB"&?;;8 B"""""18 MFB"56 "QQQQQQQQQQQQQQQQQQQQQQQQQQQQQ"""""""""18 MFB" @EE"QQQQQQQQQQQQQQQQQQQQQQQQQQQQQ"""""/E@; 6E E"QQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQ"""""#;8]?8 B"18 MFB"#7? B?6B @ E"QQQQQQQQQQQQQ"""""* 8"QQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQ"""""\?7 9 QQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQ"""""* @;8J 6"QQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQ"/6EB"&?;;8 B"""""\ M8"-6B M". E@;D8;"QQQQQQQQQQQQQQQQQQQQQ"""""""""% MFB"-6B M"3L D;@98"QQQQQQQQQQQQQQQQQQQ"""""* J 8BL"QQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQ"""""-6B M". E@;D8;"N @ EA8 : P"QQQQQQQQQQQQQ"""""\ A@76;". QQQQQQQQQQQQQQQQQQQQQQQQQQQ"""""3 F H@AF;8 6"QQQQQQQQQQQQQQQQQQQQQQQQQQQ"/6EB"&?;;8 B"E9.EGM """"S86D6 QQQQQQQQQQQQQQQQQQQQQQQQQ""""", M;6 8E"QQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQ":G.KL9N 9.4 PMK.9MY JYJLG?J EI G.4QEMK.G MGJ1KM9LQMY 4KJG9JGJ #;8]?8 B"-6;"( :8 B @ E"QQQQQQQQQQQQQQQQQQQQ"JTK. 4KJG9JGJ - I ?QQ4 .8A;8EE @ "QQQQQQQQQQQQQQQQQQQQQQQQQQQQQQ"""""/6EB"&?;;8 B"""""2 D 8L"3B@ 8E"QQQQQQQQQQQQQQQQQQQQQQQQQQQ"""""38 E@;L"( B8M;6B C8". E@;D8;"QQQQQQQQQQQQQQQQ""""" ; 6;L"';6 B"( :8 B @ "QQQQQQQQQQQQQQQQQQQ"""""*?B E9"QQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQ"""""T86EB"( :8 B @ E"QQQQQQQQQQQQQQQQQQQQQQQQQQ""""", 7D"&@M B C8"(9A6 ;98 QQQQQQQQQQ"""""* NGL9NI 19K. """"38 ?;;8 B"""""*;BF; B E"QQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQ"""""*;BF; B E"QQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQ"""""# K;@9L67M 6"QQQQQQQQQQQQQQQQQQQQQQQQQQQQ""""")BF8;"%8?;@7@M 67"/;@K789E"QQQQQQQQQQQQQQQ"""""&F;@ "/6 "QQQQQQQQQQQQQQQQQQQQQQQQQQQQ""""[""
,-.(&* "S(3')0T"N&)%'(% -.P" 1MGXKQPJ GX9NP9LKQ.J K.ZPMKGJ"/A5:O%P8J%?M%F57%D9H% 68Q?H5%HD 5%/A5:O%P8J%?M%F57%D9H% 68Q?H5%HD 5"""#?77"/FLE 67"-J69"QQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQ"""\6 G"( %8 G"( L F@7@M 67"-C67?6B @ EQQQQQQQQQQQQQQQQQQQQQQQQQQQ""18 FE78;"/;8E F@@7"b"/; 96;L""""S86D"( a?;L""QQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQ"""3 678"@:"( B877 M8 8"QQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQ"""\;@G8 "\@ 8E""QQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQ"""3A88 F"6 D" 6 M?6M8"-C67?6B @ QQQQQQQQQQQQQQQQQQQQQQQQQ"""58 8B "-C67?6B @ "QQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQ"""S86D"( ?;@7@M 67"-C67?6B @ E""QQQQQQQQQQQQQQQQQQQQQQQQQQ"""\;@G8 "\@ 8 B8;@7@ML"-C67?6B @ QQQQQQQQQQQQQQQQQQQQQQQQQQQQQ"""&87 6 V57?B8 "B8EB M""QQQQQQQQQQQQQQQQQQQQQQQQQQQQQ"""JPM:GMKGJ *778;ML"-C67?6B @ 7%D9H% 68Q?H5%HD 5"""%?B; B @ 67"-C67?6B @ ""QQQQQQQQQQQQQQQQQQQQQQQQQQQQQ"""*AA8 D8 B@9L""QQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQ"""*?D B@;L"-C67?6B @ ""QQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQ"""& ; ?9 E @ ""QQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQ""" E @ "-C67?6B @ ""QQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQ"""S8; EB8@A6BF ""QQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQ"""'@ E * ?A? B?;8""QQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQ"""*D8 @ DE""QQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQ""") ?A6B @ 67"'F8;6AL""QQQQQQQQQQQQQQQQQQQQQQQQQQQQQ""".8 ""38 E@;L"( B8M;6B @ "'F8;6AL""QQQQQQQQQQQQQQQQQQQQQQQ"""'?K8E" "-6;E""QQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQ""" 6 QQ"""3 M " 6 M?6M8""QQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQ" 6NQQ4 LY1G0 ""S@98@A6BF F ""QQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQ"""&;6 @E6 ;67""QQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQ"""&F ;@A;6 B QQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQ"""&'"3 6 ""QQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQ""" AA8;"- D@E @AL""QQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQ""" AA8;"5("38; 8E"QQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQ""" 7B;6E@? D"QQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQ" BQJ1KL9NK[9LKQ.J " %@ 8""""(:"L8EX"A786E8"7 EBI".6B8"086E@ """"""""""" " "!"*"!"\"!"*\" !")" !"0Fc" !" G @O
,-.(&* "S(3')0T"N&)%'(% -.P"K?P.K[9LKQ.J (E"L@?;" F 7D"?A"B@"D6B8"O BF" 99? H6B @ EW" eeeeeeeeeeeeeeeeeeeeeeeeeY" ! T8E" ! %@".@"L@?":887" 99? H6B @ E"F6C8"F6D"6 " 9A6 B"@ "L@?;" F 7DZE"F867BFW" eeeeeeeeeeY" ! T8E" ! %@"(:";878C6 BX"6BB6 F"6" @AL"@:"L@?;" F 7DZE" 99? H6B @ ";8 @;D"@;"E88"6DD8 D?9Y""1JYEBQJQEK9N S6E"L@?;" F 7D"8JA8; 8 8D"6 L"96a@;"7 :8" F6 M8E"BF6B"96L"F6C8" 9A6 B8D"F EVF8;"F867BFW" Y" ! T8E" ! %@"S6E"L@?;" F 7D"8C8;"8JA8; 8 8D"6 L"96a@;"7@EE8EW" eeeeeeeeeeeeeeeeeeeeeeYY" ! T8E" ! %@""JLMGJJIEQ1K.: S6C8"L@?"8C8;"E@?MFB" @? E87 M":@;"L@?;" F 7DW" eeeeeeeeeeeeeeeeeeeeeeeYY" ! T8E" ! %@"(E"L@?;" F 7D"@;":69 7L" ?;;8 B7L" "BF8;6ALW" eeeeeeeeeeeeeeeeeeeeeeeeeeYY" ! T8E" ! %@"" .8E ; QQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQ".@8E"L@?;" F 7D"F6C8"6":6C@; B8"B@L"@;"@Ka8 BW" eeeeeeeeeeeeeeeeeeeeeeeeeYY" ! T8E" ! %@"&F8 G"677"BF6B"6AA7LI"" " T@M6"" ,8D B6B @ "" (96M8;L"" \;86BF M"" " '6 "&F "" /;6L8;"" )BF8;"NA786E8"D8E ; K8P" QQQQQQQQQQQQQQQQQQQQQQQQQQQQQ""S6E"L@?;" F 7D"8C8;"K88 "6K?E8DX"6"C B 9"@:"6" ; 98X"@;"8JA8; 8 8D"6"E M : 6 B"B;6?96W""eeeeeeeeeeeeeeeeeeeeeeeeeeeeeeYYY" ! T8E" ! %@""JNGG1IMGJL *C8;6M8" ?9K8;"@:"F@?;E"L@?;" F 7D"E788AE"6B" MFBI"! f!4"! !g !4" ! h !g" ! ih".@8E"L@?;" F 7D"F6C8"B;@?K78":677 M"6E788AW"" eeeeeeeeeeeeeeeeeeeeeeeeeeYY" ! T8E" ! %@".@8E"L@?;" F 7D":887";8EB8D"?A@ "6O6G8 MW"" eeeeeeeeeeeeeeeeeeeeeeeeeYY" ! T8E" ! %@".@8E"L@?;" F 7D"E @;8W""eeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeYYeYY" ! T8E" ! %@""MQNGJIMGN9LKQ.JBK1 1?7 %&D;? F%)5;P567L%#69 7L",89K8;"6 D"0876B @ EF A"*M8"58 D8;" 1F@"6;8"BF8"96 "A8@A78"OF@" 6;8":@;"L@?;" F QQQ"'F8 ;"-9A7@L98 BV) ?A6B @ I" QQQQQQQQQQQQQQ"08E@?; 8E":@;"89@B @ 67"E?AA@;BW"/A5:O%D % AD %D FL"" 3A@?E8"" #69 7L"" #; 8 DE"" 087 M @?EV3A ; B?67"" /8BE"" )BF8;"NA786E8"7 QQQQQ"""d"
5T%-&) )5(&"S(3')0T"NM86%R8;59%89 FP""?G.JLMP9N BKJLQMY *M8"6B": ;EB"A8; @DI"QQQQQQQQQQQQQQQQ" ,8 E8E"#;8]?8 LI"QQQQQQQQQQQQQQQ" 8 MBFI"QQQQQQQQQQQQQQQQ"/6 I"" eYY" ! T8E" ! %@"&7@BB MI"" Y" ! T8E" ! %@"S6E"L@?;"A8; @D"8C8;"EG AA8DW""eeeeeeeeeeeeeYeeeeeeeeeeeeeeeeeeeYYeYY" ! T8E" ! %@"#@;"F@O"7@ MW"" QQQQQQQQQQQQQQQQQQQQQQQQQQQQQ" 6EB",8 EB;?67"/8; QQQQQQQQQQQQQQQQQQQQQQQQQQQ" E8"@:"F@;9@ 67" @ B;6 8AB @ "E? F"6EI"" \ ;BF"&@ B;@7"/ 77E"" /6B F""" %?C6"0 M"S@O"7@ MW"" QQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQ".@"L@?"?E8" @ B;6 8AB @ W""eeeeeeeeeeeeeYeeeeeeeeeeeeeeeeeeeYYeYY" ! T8E" ! %@"(:"L8EX"OF F"BLA8W"" &@ D@9"" . 6AF;6M9"" ( ."" /6;B 8;" 6E8 B@9L"5("S(3')0T""S6E"L@?;" F 7D"B;6C878D"B@":@;8 M " @? B; 8EW" eeYYeeeeeeeeeeeeeeeeeeeeeeYYY" ! T8E" ! QQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQ"1 7D8; 8EE"&69A MW"" eeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeYYYY" ! T8E" ! C8;"F6D"E8C8;8I""" 56EB;@8 B8; B E"" . 6;;F86".-%'* "S(3')0T"3 7C8;",8; ?;L"# 77 ME"(:"L8EX"F@O"96 QQQQQQQ"" 5@7D"# 77 ME"" 0@@B"&6 67E"" (9A76 BE"" '@@BF"/6 "" \788D M"5?9E"" 5 M C B E"" /;@K789E"O BF"&F8O M".@"L@?":7@EE";8M?76;7LW" eeeeeeeeeeeYYeeeeeeeeeeeeeeeeeeeeeeeeee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j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h"
/*'(-%'"\(0'S"S(3')0T"N&)%'(% -.P "/0-5%*%&T"'@B67"O8 MFB"M6 "D?; M"A;8M 6 LI"QQQQQQQQQ"7KEY" '@B67"O8 MFB"7@EE"D?; M"A;8M 6 LI"QQQQQQQQQ"7KEY"/786E8"D8E ; K8"D 8B"D?; M"A;8M 6 LI/786E8"D8E ; K8"76K@;I 1GMK.9L9N /;8M 6 L"D?;6B @ I"N%M8 8R?9@% A5%R55O%8M%@57 D ?89%! 24 ! 25 ! 26 ! 27 ! 28 ! 29 ! 30 ! 31 ! 32 ! 33 ! 34! 35 ! 36 ! 37 ! 38 ! 39 ! 40 (full term)! 41 ! 42 ! 43 ! 44 Weeks 8;L"6 B C8"K8:@;8"K ;BFW"" eeeeeeeeeeeYYeeeeeeeeeeeeeeeeeeeeeeeeeYYY" ! T8E"S@EA B67V\ ;BF M"&8 B8;W"" eeeeeeeeeeeYYeeeeeeeeeeeeeeeeeeeeeeYeeYYY" ! T8E"%88D8D"%8OK@; "3A8 67"&6;8W""eeeYeeeYYeeeeeeeeeeeeeeeeeeeeeeeeeeYYY" ! eeeeeeeeeeeeeeeYYY" ! T8E"-6E 7L" @ E@78D"D?; M": ;EB"9@ BFW""eeeeYYeeeeeeeeeeeeeeeeeeeeeeeeeeYYY" ! T8E"* B K @B E": ;EB"9@ BFW""eeeeeeeeeeeYYeeeeeeeeeeeeeeeeeeeeeeeeeeYYY" ! T8E"-JA8; 8 8D" @" @9A7 6B @ E": ;EB"9@ BF"@:"7 :8W"eeeeeeeeeeeYYeeeeeeeeeee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months "! 2-6 months "! 6-15 months "! 16-24 months "! After 24 months(E"BF E" 9A;8EE @ "EF6;8D"69@ M"A6;8 BE"6 D"@BF8;E" 6; M":@;"BF8" F 7DW "eeeeeeeeeeeYYY" ! T8E".@8E"BF E" 9A;8EE @ X"6E"BF8"B 9 M"@:"@ E8BX"D ::8;"69@ M"A6;8 BE"6 D"@BF8;E" 6; M":@;"BF8" F 7DW""eeeeeeeeeeeYYeeeeeeeeeeeeeeeeeeeeeeeeeYYY" ! T8E"(E"BF8" 9A;8EE @ X"6E"B@"BF8"B 9 M"@:"@ E8BX"O86GW"eeeeeeeeeeeeeeeeeeeeeeeeYYY" ! T8E");" E"BF E" 9A;8EE @ "EB;@ MW "" eeeeeeeeeeeYYeeeeeeeeeeeYeeeeeeeeeeeeYYY" ! T8E""k"!!!!%@"%@"%@"%@"
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g"
,-.(&*'()%3 EPMMG.L ?G4KE9LKQ.J MedicationsDoseFrequencyStart Date (month/year)Reason For UsePREVIOUS MEDICATIONS: Last 10 yearsMedicationsDoseFrequencyStart Date (month/year)Reason For UseNUTRITIONAL SUPPLEMENTS (VITAMINS/MINERALS/HERBS/HOMEOPATHY)Supplication and BrandDoseFrequencyStart Date (month/year)Reason For Use"S6C8"L@?;"98D 6B @ E"@;"E?AA7898 BE"8C8;" 6?E8D"L@?"? ?E?67"E D8"8::8 BE"@;"A;@K789EW" ! T8E" ! %@"" .8E ; A;@7@ M8D"@;";8M?76;"?E8"@:"%3*(.3"N8YMYX"*DC 7X"*78C8PX",@B; X"*EA ; W"YYYY" ! T8E" ! %@"S6C8"L@?"F6D"A;@7@ M8D"@;";8M?76;"?E8"@:"'L78 @7""eYeeeeeeeeeeYYeeeeeeeeeeYYYY" ! T8E" ! %@"S6C8"L@?"F6D"A;@7@ M8D"@;";8M?76;"?E8"@:"* D"\7@ G M".;?ME"N8YMYX"'6M698BX"l6 B6 X"/; 7@E8 P"eeeeeeeeeeeeeeYeeeeeeeeeeeeeeeeeeeeeeeeeeeYYYe" ! T8E" ! %@"#;8]?8 B"6 B K @B E"f"R"B 98EVL86;"eeeYYeeeeeeeeeeYYeeeeeeeeeeeeeeeeeYYY" ! T8E" ! %@" @ M"B8;9"6 B K @B E" eeeYYeeeeeeeeeeYYeeeeeeeeeeeeeeeeeeeeeeeeeYY" ! T8E" ! %@" E8"@:"EB8;@ DE"NA;8D E@ 8X" 6E67"6778;ML" F678;EP" "BF8"A6EB"eeeYeeeeeeeeeeeeYYY" ! T8E" ! %@" E8"@:"@;67" @ B;6 8AB C8E" eeeeeeeeeeeYYeeeeeeeeeeeYeeeeeeeeeeeeeYYYY" ! T8E" ! %@""!!"
"/A5:O%MD;? F%;5;P567% AD %D F%,@BF8;"#6BF8;"\;@BF8;NEP"3 EB8;NEP"&F 7D;8 "*? BE" 78E")BF8;"",6B8; 67"5;6 D9@BF8;",6B8; 67"5;6 D:6BF8;"/6B8; 67"5;6 D9@BF8;"/6B8; 67"5;6 D:6BF8;"#*,( T"S(3')0T *M8"N :"EB 77"67 C8P"*M8"6B"D86BF"N :"D E86E8DP"&6 8;E"&@7@ "&6 8;"\;86EB"@;")C6; 6 "&6 8;"S86;B". E86E8"SLA8;B8 E @ ")K8E BL". 6K8B8E"3B;@G8"( :76996B@;L"*;BF; B E"N0F8?96B@ DX"/E@; 6B X"* GL7@E M"3@ DL7 B EP"( :76996B@;L"\@O87". E86E8",?7B A78"3 78;@E E"*?B@"(99? 8". E86E8E"NE? F"6E" ?A?EP"(;; B6K78"\@O87"3L D;@98"&87 6 ". E86E8"*EBF96"- H896V/E@; 6E E"#@@D"*778;M 8EX"38 E B C B 8E"@;"( B@78;6 8E"- C ;@ 98 B67"38 E B C B 8E".898 B 6"/6;G E@ ZE"* 3"@;"@BF8;",@B@;"%8?;@ ". E86E8E"58 8B ". E@;D8;E"3?KEB6 8"*K?E8"NE? F"6E"67 @F@7 E9P"/EL F 6B; ". E@;D8;E".8A;8EE @ "3 F H@AF;8 6"*.S."*?B E9"\ A@76;". """"""""""""""""""""""""""""!4"
% '0('()%"S(3')0T "S6E"L@?;" F 7D"8C8;"F6D"6" ?B; B @ " @ E?7B6B @ W""eYeeeeeeeeeeYYeeeeeeeeeeYYYY" ! T8E" ! %@"S6C8"L@?"96D8"6 L" F6 M8E" "L@?;" F 7DZE"D 8B"K8 6?E8"@:"F867BF"A;@K789EW"eYeeeeeYYYY" ! T8E" ! %@"" .8E ; QQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQ".@8E"L@?;" F 7D":@77@O"6"EA8 67"D 8B"@;" ?B; B @ 67"A;@M;69W"eeeYeeeeeeeeeeeYeYYYY" ! T8E" ! %@"/A5:O%D % AD %D F%" .6 ;L"#;88"" . 6K8B "" #8 M@7D"" 57?B8 "08EB; B8D"" 57?B8 V&6E8 "#;88"" 28B@M8 "" @O")J676B8"" 3A8 : "&6;K@FLD;6B8"" 8M6 "" 8M8B6; 6 "" 18 MFB",6 6M898 B" " 1F86B"#;88"" T86EB"#;88"" #@@D"*778;ML"N8YMYX% 5D9C 7W%5@@7VL"" QQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQ""S8 MFB"N:88BV F8EP""QQQQQQQQQQQQQQQQQQQQQQQQQQQ" &?;;8 B"18 MFB"" QQQQQQQQQQQQQQQQQQQQQQQQQQQQQQ" @ M8EB"18 MFB"#7? B?6B @ E"eeeYY" ! T8E" ! %@" "".@8E"L@?;" F 7D"6C@ D"6 L"A6;B ?76;":@@DEW"eeeYeeeeeeeeeeeYeeeeeeeeeeee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a? 8" B6G8"#% 6B"9@;8"BF6 "[gm"9867E"6O6L":;@9"F@98"# " @O":;? BVC8M8B6K78" B6G8"#/% @@;"E 6 G" F@ 8E"#S" MF"E?M6;VEO88B" B6G8"#3% 8 E@;L" EE?8E"O BF":@@D"#5" 8EB6B @ 67"#/% GL"86B8;"#S" MF"K7@@D"A;8EE?;8NA;8"# % 9 B8D"C6; 8BL"@:":@@DE"i"[VD6L"#S" MF"K7@@D""#/% ;8:8;E" @7D":@@D"#S" 6C8" F89 67"8JA@E?;8""#"/;8:8;E"F@B":@@D""#"-C8;L"9867" E"6"EB;?MM78""\0-*3'#-."S(3')0T"\;86EB:8DW" YY" ! T8E" ! %@"'LA8"@:":@;9?76I"" 3@L"" &@OZE", 7G"" @O"*778;ML"( B;@D? B @ "@:" @OZE"9 7G"6B"QQQQQQQQQQ"9@ BFEY"# ;EB":@@DE" B;@D? 8D"6B"QQQQQQQQQ"9@ BFEY""( B;@D? B @ "@:"E@7 D":@@DE"6B"QQQQQQQQQQQ"9@ BFEY"( B;@D? B @ "@:"OF86B"@;"@BF8;"M;6 "6B"QQQQQQQQQQ"9@ BFEY!R"
% '0('()%"S(3')0T"N&)%'(% -.P \0-*3'#-."S(3')0TX"N&@ BYP"&F@G8V56EV @9 B"@ "9 :?E8D"B@" F8O"E@7 DEW""eYeeeeeeeeeeeeeeeeeeeeeeeeeeeYeeeeeeYYee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j"( E D8"/8EB"8JB8;9 6B @ "j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j"/-03)%* ",)'S-0"j"/-03)%* "*M8"6B"L@?;"K ;BF""QQQQQQQQQQQQQQQQQQQQQQQQQQQQQ" *M8"6B"L@?;"K ;BF""QQQQQQQQQQQQQQQQQQQQQQQQQQQQQ"-BF BL"" QQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQ" -D? 6B @ ""QQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQ"-D? 6B @ "" QQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQ" -BF 8"" QQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQ" \7@@D"BLA8"" QQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQ"!U"
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a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j"C8;L"EO86BL"# ( 6K 7 BL"B@"B6 "# G8"B@"K8"EO6DD78D"# /8;EA ;6B @ "j"@DD"@D@;"# MFB"K ;BF"96;GNEP" # 06MM8D" ?B 78E"JNGG1 JTK. # 'F G8 M": M8; 6 7E"# 3788AE" "@O "K8D"# /678 8EEX"E8C8;8"# 'F G8 M"B@8 6 7E"# 3788AE"O BF"A6;8 BNEP"# #? M?EV": M8; 6 7E"# B 7 M@"# *O6G8 E"E ;869 MV" ;L M"# #? M?EV"B@8 6 7E"# 1F B8"EA@BE"@:"7 8E" " 6 7E"# *O6G8E"6B" MFB"# .6 D;?::"# .;L"EG " "M8 8;67"# . :: ?7BL":677 M"6E788A"# &F G8 "EG "# #88B" ;6 G M"# -6;7L"O6G M"# ) 7L"EG "# S6 D"A887 M"# ( E@9 6"# /6B FL"D?77 8EE"# @O8;"78ME"D;L"# 3788AE"78EE"BF6 " @;967"# 38K@;;F86"@ ":6 8"# 3G "76 G7?EB8;"# .6LB 98"E788A 8EE"# 'F G" 677?E8E"# (B FL"EG " "M8 8;67"# n8;GE"D?; M"E788A"# *BF78B8E":@@B"# (B FL"E 67A"# % MFB96;8E"# #88B"j"EB GL"# (B FL"86;" 6 67E"# 3788AE"9@;8"BF6 " @;967"# . 6A8;";6EF"# (B FL"8L8E""# )DD"K@DL"@D@;"# (B FL" @E8""!["
3T,/'),"0- (-1"N&)%'(% -.P 3 5D75%:A5:O%D %:C6659 %7F; 8;7%8::C66?9@%86% 65759 %?9% A5% D7 %X%;89 A7E%"JTK.] E";57; '3 4K:GJLKXG] E";57; '3 G9LK.:] E";57; '3 # (B FL";@@:"@:"9@?BF"# #6;B M"j";8M?76; # 3A8 : ":@@DNEP" B@78;6 8"# (B FL"6;9E"# #6;B M"j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a8 BE"F87A"# 3@;8"BF;@6B"# &;6C M":@;" 6;K@FLD;6B8E"# &?; @?EV"M8BE" B@"BF ME"# #8 67"K87 F M"# &;6C M":@;"a? 8"# -;;6B "# \?;A M"# &;6C M":@;"E67B"# 6K78"B@"A;8D B"6 B @ E"# %6?E86"# . 8B"E@D6" ;6C M"# .8EB;? B C8"# 08:7?J"# / 6"N86B M" @ 8D K78EP"# SLA8;6 B C8"# 3A BB M"?A"# *K @;967":@@D" ;6C ME"# &@ EB6 B"9@C898 B"# @9 B M"# &6;K@FLD;6B8" B@78;6 8"# ,87BE"D@O "# *KD@9 67"K7@6B M"# 3B6; FV"D E6 F6; D8"# '6 B;?9E" B@78;6 8"# @O8;"6KD@9 67"K7@6B M"# 387:"9?B 76B @ "# &@7 "# 3?M6;" B@78;6 8"# 0? E"6O6L"# *KD@98 "D EB8 D8D"# 367 L76B8" B@78;6 8"# n?9AE"OF8 "A786E8D"# *KD@9 67"A6 "# )J676B8" B@78;6 8"# 1F ;7E"E87:"7 G8"6"B@A"# ( B8EB 67"A6;6E B8E"# /F8 @7 E" B@78;6 8"# &7 9KE"B@"F MF"A76 8E"# / O@;9E"# ,35" B@78;6 8"# ( E EBE"@ "OF6B"O6 B8D"# &;69A M"A6 "O BF"A@@A M"# #@@D" @7@; M" B@78;6 8"# '; 8E"B@" @ B;@7"@BF8;E"# &@ EB A6B @ "# 57?B8 " B@78;6 8"# S86D"K6 M M"# . 6;;F86 # &6E8 " B@78;6 8""! "
3T,/'),"0- (-1"N&)%'(% -.P 3 5D75%:A5:O%D %:C6659 %7F; 8;7%8::C66?9@%86% 65759 %?9% A5% D7 %X%;89 A7E%"6GB9XKQM] E";57; '3 ?QQ4] E";57; '3 JG.JQMY] E";57; '3 # #677EX"M8BE"F?;B";? M"# .@8E" @B"O6 B"B@"K8"B@? F8D"# 3B;6K E9?E"N ;@EE8D"8L8P" 7 9K M"# ( @ E@76K78" ;L M"# #86;:?7"@:"F6;978EE"@Ka8 B"# .@8E"@AA@E B8"@:"6EG8D"# (;; B6K78"# #86;:?7"@:"? ?E?67"8C8 BE"# 3 77L"# @@GE"7 G8" "A6 "#
INTAKE FORMS PEDIATRIC For ages 0-13 years THESE FORMS MUST BE SUBMITTED TO OUR OFFICE AT LEAST 7 DAYS PRIOR TO YOUR FIRST APPOINTMENT Due to sensitivities, our office is fragrance free. We ask that you DO NOT wear scented products to our office. This includes per
Communication Skills Learning Tools for the Pediatric Clerkship 37 Pediatric History Taking Approach to the Pediatric Patient 38-39 Explanation of Pediatric H&Ps/Pediatric Database 40-43 Example H&Ps (older child and infant) 44-52 Pediatric Physical Examination Benchmarks for Pediatric Physical Examination 53 54-65
The physicians at Albany Med's Bernard & Millie Duker Children's Hospital are specially trained in more than 40 pediatric fields, including pediatric pulmonary disease, pediatric surgery, pediatric gastroenterology, pediatric anesthesia and pediatric neurology. Albany Med houses the region's only Pediatric Intensive Care Unit (PICU) and
the factory intake to the new RDP intake. Then install the intake support hand tight. Step 11: Install the RDP Cold Air Intake into the vehicle with the remaining hose clamp. Connect the PCV silicone tube to the intake, and reconnect the MAF sensor. Note: The silicone P
Jan 27, 2016 · Family Therapy Intake Package - New Client Forms . Use these forms instead of the General Intake Package, if the therapy includes any one person under the age of 18 . INSTRUCTIONS FOR ENCLOSED FORMS. Parent(s) should complete forms 1 through 8 below. If only one par
Intake Air System - MX-5 Miata INTAKE AIR SYSTEM HOSE ROUTING DIAGRAM [LF] Fig. 1: Identifying Intake Air System Hose Routing Diagram Courtesy of MAZDA MOTORS CORP. INTAKE AIR SYSTEM LOCATION INDEX [LF] 2007 Mazda MX-5 Miata Sport 2007 ENGINE PERFORMANCE Intake Air System - MX-5 Miata Microsoft
PAGE 18 OF 25 REF. NO. DESCRIPTION B7 Intake Adapter, RH (or Rear Intake Adapter, RH) B12 Intake Flange Gasket B22 Hex Hd Screw, 1/2-13 x 1-1/4 in. B23 Hex Hd Screw, 3/4-10 x 2 in. B35 Square Hd Pipe Plug, 3/8 in. B62 Flap Valve, Rear Intake B63 Rear Intake Fitting Gasket B74 Rear Intake Fitt
Intake – R.D. obtains diet history and estimates energy needs. Suboptimal intake is determined as a percentage of estimated need over time. Energy Intake 75% energy intake compared to estimated energy needs for 7 days . Energy Intake 75% energy intake compared to estimated e
Buku Saku Keperawatan Onkologi. Jakarta: EGC Pugalendhi, P. dan S. Manoharan. 2010. Chemopreventive Potential of Genistein and Daidzein in Combination during 7,12-Dimethylbenz (α)anthracene (DMBA) induced Mammary Carcinogenesis in Spray-Dawley Rats. Pakistan Journal of Biological Sciences. 13 (6): 279-286 Purwanto, Djoko Agus dan Achmad Toto Purnomo. 1999. Penetapan Kadar Metil Pada Hasil .
