The maryland tobacco quitline 1800quit now 18007848669 sara wolfe, ms 300 west preston street, suite 410 baltimore, md 21201 4107671364 swolfe dhmh.state.md.us quitlines: clinical and community interventions according to the u.s. public health...
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Name: chart: dob: date of visit jewett orthopaedic clinic, pa medical history - page 1 age: height: weight: primary physician: please note, items left blank indicate a negative response. past medical history bleeding disorders blood clots/dvt...
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Diabetes pim chart questions no. question text responses 1 the patient identifier below is for your reference only. some physicians choose to enter a medical record number or patient initials. any combination of letters and numbers that are...
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Diabetes mellitus cap patient visit form please complete the form below for the required number of patients meeting patient sample criteria for the measure group (20 for cap only, 30 medicare part b fee-for-service for cap plus pqrs). for the 2011...
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Arkansas state highway and transportation department form p-359 rev. 3-1-2005 tabulation description: supply contract for furnishing mobile radios and equipment bid no.: h-06-003p date opened: 5/24/2005 (motorola cdm 1550-ls) for the period...
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This form is available electronically. -471 nap bp (02-05-09) u.s. department of agriculture commodity credit cooperation noninsured crop disaster assistance 2009 and subsequent years basic provisions (this is a continuous application for...
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Home blood pressure log you can complete the highlighted fields on this form online and then print the form for easy reference. only text that is visible on the form is printed; scrolled text will not print. any text you enter into these fields...
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Practice enhancement examples blood glucose record a. enhancement objective a blood glucose record provides a log of patients' blood glucose readings to guide adjustments in pharmacotherapy for diabetes. 10 enhancement author: lisa mccarthy...
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Blood pressure record chart name: address: date and time systolic blood pressure diastolic blood pressure comments for heart health information 1300 36 27 87 .heartfoundation.org.au 2008 national heart foundation of australia abn 98 008 419 761
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Name: date of birth: year month fasting blood sugar phone: lunch dinner blood sugar affter meal blood sugar before meal carb dose blood sugar affter meal breakfast carbs dose blood sugar after meal blood sugar before meal bedtime blood sugar level...
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Cap member health history form this information is confidential and for official use only. it cannot be released to unauthorized persons. answer all questions as accurately as possible so that the activity or encampment staff can make themselves...
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Dane county department of public works, highway and transportation county executive joseph t. parisi 1919 alliant energy center way madison, wisconsin 53713 phone: (608) 266-4018 fax: (608) 267-1533 commissioner / director gerald j. mandli best...
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Fitness assessment form name (last, first) birth date / / age: weight lb kg assessment date / / resting blood pressure / height in. sex m / f body composition bioelectrical impedance reading: resting hr % body fat: % body fat % lean mass: bmi...
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2009 - 10 week wellness program program tracking formactivitywalk for 30 minutes three days a week exercise three days a week other than walking encourage a co-worker to exercise with you commit a random act of kindness give blood get a flu shot...
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Form no. f-a-17/02 medical certificate of fitness (format) certified that i have carefully examined mr./mrs. s/o/d/o r/o height weight age eye-sight blood pressure normal (yes/no) please specify deformity if any, (particularly in hands) on the...
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