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Name: __________________________________________ Date of Birth: ________________________ Name: _________________________________Gender: Male Female Last 4 of SS #: _________ Date of Birth: ________________________ Place of Birth:_________________________________ Address: _____________________________________________________________________________ City: ________________________________________ State: _____ Zip Code: __________________ Phone Number: _______________________________ Cell Phone: _____________________________ Work Number: _______________________________ Email: _________________________________ What is the best way to contact you? _________________________________________________ Marital Status: Single Married Widowed Divorced Other: _________________ Ethnicity: Hispanic or Latino Not Hispanic or Latino Unknown Declined to specify Race: Asian Black or African America Native American Indian Native American Indian or Alaska Native Native Hawaiian Other Pacific Islander White Preferred Language: _______________________ Would you like to have a translator free of charge provided during your office visits: Yes No Religion:_________________________________ Do you have an advance directive? 0 Living will 0 Medical Durable Power of Attorney 0 Do Not Resuscitate 0 CPR Directive 0 MOST form 0 Other

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  • Name: __________________________________________ Date of Birth: ________________________

    Name: _________________________________Gender: Male Female Last 4 of SS #: _________

    Date of Birth: ________________________ Place of Birth:_________________________________

    Address: _____________________________________________________________________________

    City: ________________________________________ State: _____ Zip Code: __________________

    Phone Number: _______________________________ Cell Phone: _____________________________

    Work Number: _______________________________ Email: _________________________________

    What is the best way to contact you? _________________________________________________ Marital Status:

    � Single � Married

    � Widowed � Divorced

    � Other: _________________

    Ethnicity:

    � Hispanic or Latino � Not Hispanic or Latino � Unknown � Declined to specify

    Race:

    � Asian � Black or African America � Native American Indian � Native American Indian or Alaska

    Native � Native Hawaiian � Other Pacific Islander � White

    Preferred Language: _______________________

    Would you like to have a translator free of charge provided during your office visits: Yes No

    Religion:_________________________________

    Do you have an advance directive?

    0 Living will 0 Medical Durable Power of Attorney 0 Do Not Resuscitate

    0 CPR Directive 0 MOST form 0 Other

  • Name: __________________________________________ Date of Birth: ________________________

    Emergency Contact Information:

    Name: __________________________________________ Relationship: ________________________

    Address: _____________________________________________________________________________

    City: ________________________________________ State: _____ Zip Code: ___________________

    Phone Number: ________________________________ Cell Phone: _____________________________

    Work Number: ________________________________ Email: _________________________________

    Medical Care:

    Primary Care Physician: ____________________________________ Phone #: ____________________

    Referring Physician: _______________________________________ Phone #: _____________________

    Employment: Are you retired? Yes No (if yes please skip to insurance information)

    Employer’s Name: ____________________________________Occupation: _______________________

    Employer’s Address: ___________________________________________________________________

    City: ________________________________________ State: _____ Zip Code: ___________________

    Spouse Employer’s Name: ______________________________Occupation: ______________________

    Employer’s Address: ___________________________________________________________________

    City: ________________________________________ State: _____ Zip Code: ___________________

    Insurance Information:

    Please bring the most updated insurance card(s) to your visit.

    Primary Insurance: __________________________________________________________________

    Address: _____________________________________________________________________________

    City: ________________________________________ State: _____ Zip Code: ___________________

    Policy Holder Name : ________________________________ Policy Holder DOB: _________________

    Policy Holder SSN: ______________________Insurance ID #: ______________Group #: ___________

  • Name: __________________________________________ Date of Birth: ________________________

    Reason for your visit: __________________________________________________________________

    Medications: Please bring a list of CURRENT medication to your visit; include name, dose, and frequency of medication (please include any over the counter medications).

    Allergies and reactions:

    _____________________________________________________________________________________

    _____________________________________________________________________________________

    _____________________________________________________________________________________

    _____________________________________________________________________________________

    Pharmacy: ___________________________________________________________________________

    Pharmacy Address: ____________________________________________________________________

    Pharmacy Phone #: ___________________________________________________________________

    Lifestyle

    Diet

    � Well Balance � Vegetarian

    � Diabetic � Weight Loss/Fad

    � Excessive Fat / Calories

    Do you consume caffeinated products? Yes No

    Type__________________________________________ Amount_________________________

    Do you consume alcohol? Never Former Current (former and current fill in information below)

    Type__________________________________________ Amount_________________________

    Frequency:________________ Year quit:______________________

    Do you exercise regularly? Yes No

    Type: ____________________________________ Frequency: __________________________

    Do you use tobacco? Never Former Current (former and current fill in information below)

    Type: _______________________________ Packs/day______________ Years Used: ________

    Age started: ____________ Age stopped: _____________

    Ever try to quit: Yes No Years quit: ______ Reason for Relapse: ____________________

    Are you exposed to passive smoke (second-hand)? Yes No

  • Name: __________________________________________ Date of Birth: ________________________

    Have you used illicit drugs? Never Former Current (former and current fill in information below)

    Type__________________________________________ Amount_________________________

    Frequency:________________ Year quit:__________________

    Family History of Heart Disease Yes No (If yes, complete the information below.)

    Relationship: ___________ Age: ______ Type of Heart Disease:_________________________

    Age of Death? _____ Cause of Death? _____________________________________________

    Relationship: ___________ Age: ______ Type of Heart Disease:_________________________

    Age of Death? _____ Cause of Death? _____________________________________________

    Relationship: ___________ Age: ______ Type of Heart Disease:_________________________

    Age of Death? _____ Cause of Death? _____________________________________________

    Have you had any of the following Cardiac Studies?

    Echo or Stress Echo Yes No When: ___________ Where: ______________________

    Nuclear Cardiac Study Yes No When: ___________ Where: ______________________

    Calcium Score Yes No When: ___________ Where: ______________________

    If you have a copy of any past medical history and/or test result(s) please bring them to your appointment or drop off at our office prior to your appointment.

    Please list any recent hospitalizations and/or surgery and ALL cardiac procedures:

    ______________________________________ When: ___________ Where: ______________________

    ______________________________________ When: ___________ Where: ______________________

    ______________________________________ When: ___________ Where: ______________________

    ______________________________________ When: ___________ Where: ______________________

    ______________________________________ When: ___________ Where: _____________________

  • Name: __________________________________________ Date of Birth: ________________________

    Have you ever had any of the following?

    Abnormal EKG Yes No When: __________________________

    Aneurysm Yes No When: __________________________

    Aortic Valve Replacement Yes No When: __________________________

    Asthma Yes No When: __________________________

    Atrial Fibrillation (A-fib) Yes No When: __________________________

    Cancer Yes No When: __________________________

    Clotting Disorder Yes No When: __________________________

    Congenital Heart Disease Yes No When: __________________________

    COPD Yes No When: __________________________

    Coronary Artery Disease (CAD) Yes No When: __________________________

    Deep Vein Thrombosis (DVT) Yes No When: __________________________

    Diabetes Mellitus (DM) Yes No When: __________________________

    Heart Failure Yes No When: __________________________

    Heart Murmur Yes No When: __________________________

    Heart Value Problem Yes No When: __________________________

    Hyperlipidemia (High Cholesterol) Yes No When: __________________________

    Hypertension (High Blood Pressure) Yes No When: __________________________

    Kidney Disease Yes No When: __________________________

    Mitral Valve Disease Yes No When: __________________________

    Myocardial Infarction (Heart Attack) Yes No When: __________________________

    Pulmonary Embolism (PE) Yes No When: __________________________

    Sleep Apnea Yes No When: __________________________

    Stroke (CVA/TIA) Yes No When: __________________________


Last Name First Name Birth Date Death Date Plot/Section

Sr.No. Date of Birth Name address M.No. Birth Month

CHANGING THE FATHER’S NAME ON A BIRTH CERTIFICATE · CHANGING THE FATHER’S NAME ON A BIRTH CERTIFICATE In order to change the father’s name on a child’s birth certificate,

Row Veteran Name First Name Last Name Birth Date Hometown ... · Row Veteran Name First Name Last Name Birth Date Hometown County State Country Branch of ServiceCasualty DateRank

1899 NAME SEX BIRTH DATE BIRTH PLACE FATHER ...negenweb.net/NEWebster/births_1850_1899.pdfWEBSTER COUNTY BIRTHS 1850 - 1899 NAME SEX BIRTH DATE BIRTH PLACE FATHER NAME MOTHER NAME

Sr.No.P.F.No. Employee Name Department Designation Birth

Amending a Birth Certificate After a Court Order Name · PDF fileAmending a Birth Certificate After a Court Order Name ... registrant’s name on a birth certificate unless the registrant

First Name Birth-Death Block Lot Military Service Notes ... · PDF fileFirst Name Birth-Death Block Lot Military Service Notes/Comments ... Alm Denise 1959 ... First Name Birth-Death

ROLL Candidate Name Father's Name Date of Birth …updgme.in/docs/295All_Merit.pdf · ROLL Candidate Name Father's Name Date of Birth Gender CATEGORY SUBCATNEET Marks Percentile NEET

LAST NAME FIRST NAME MIDDLE NAME BIRTH/DEATH · PDF fileLAST NAME FIRST NAME MIDDLE NAME BIRTH/DEATH ... Alkan Charles Henri (1813-1888) ... Bertini Henri Jerome (1798-1876)

Rollno Name Father Name Date of Birth Gender UPCategory

NAME: DATE OF BIRTH: PLACE OF BIRTH: CITIZENSHIP: …

Pulmonary Hypertension For Cardiologists

Name Birth Date Death Date Name Birth Date Death · PDF fileName Birth Date Death Date Name

for Johnny Smith - 12reports.com · SUMMARY CHART Birth name: Jonathan Joseph Smith Short name: Johnny Smith Birth date: October 16, 1975 Birth name: Maria Salvias Anthony Short name:

Deceased Name Date of Birth Place of Birth Sex Ind

PlotDataWebGL Birth Death Burial Last Name First Name ... · PlotDataWebGL Last Name First Name Grave Location Birth MM DD YYYY Birth Place Death MM DD YYYY Death Place Burial MM

Sr. No. Name, Father's/Husband's name & Address Date of Birth

TITUS COUNTY 1996 BIRTH INDEX NAME BIRTH DATE SEX 1

Place Entry # Exhibitor Name Animal Name Birth Date 025

Player First Name Player Last Name Birth Certificate ZACHERY … › portals › 1768 › docs... · 2020-06-26 · Player First Name Player Last Name Birth Certificate ZACHERY ABELN

Your Date of Birth: Baby's Name Baby's Date of Birth: … Number __ Edinburgh Postnatal Depression Scale 1 (EPDS) Name: Address: _ Your Date of Birth: _ Baby's Name Baby's Date of

First name Family name Date of birth Place of birth Age ... name Family name Date of birth Place of birth Age Residence Date of death Place of death ETEL ZVIZON LITHUANIA LITHUANIA

Cardiologists, LC newsletter

Practice Factors Affecting Cardiologists’

Pradeep Srivastava - Reputed Cardiologists

Birth Records 1915 - Year Surname Name Boy Girl Birth Date Notice

Name: Career Record: Alias: Birth Name: Nationality ...boxingbiographies.co.uk/assets/applets/Jack_Sharkey-bb.pdfName: Jack Sharkey Career Record: click Alias: Boston Gob Birth Name:

First name Family name Place of birth Date of birth Age ...€¦ · First name Family name Place of birth Date of birth Age Residence Place of death Date of death ... LATVIA 01/07/1941

for Brad Pitt - Astrologic Answers · Birth name: William Bradley Pitt Short name: Brad Pitt Birth date: December 18, 1963 Birth name: Angelina Jolie Voight Short name: Angelina Jolie

Pradeep Srivastava - Famous Cardiologists

Last Name First Name Maiden Name Birth Date Death Date

CURICULUM VITAE First name: Last name: Data of Birth: Sex ... · 1 CURICULUM VITAE First name: Shaghayegh Last name: Haghjooy Javanmard Data of Birth: 25.04. 1978 Place of Birth:

Place Entry # Exhibitor Name Animal Name Birth Date 032

 · Name _____ Birth Date _____ Place _____ Death Date _____ Place _____ Name _____