1. Name of your regular family doctor ______________________________________ Phone _____________________ OR ❏ I do not have a regular family doctor 2. Have you ever had any problems with blood pressure, previous heart disease, palpitations or angina? ❏ Yes ❏ No If yes, please explain: _______________________________________________________________________________ 3. Have you had an EKG in the past? ❏ Yes ❏ No If yes, where? when _________________________________________4. Have you had any ❏ breathing problems, ❏ asthma, ❏ hay fever, ❏ chronic bronchitis, ❏ emphysema or 5. Have you had any ❏ seizures, ❏ convulsions, ❏ migraine headaches, ❏ fainting spells or ❏ stroke?6. Have you had ❏ jaundice, ❏ hepatitis, ❏ liver disease or ❏ blood transfusion reactions?7. Do you have ❏ diabetes, ❏ hypoglycemia or ❏ thyroid problems?8. Do you have kidney problems? ❏ Yes ❏ No 9. Have you had ❏ a cold, ❏ sore throat, or ❏ flu in the last two weeks?10. Any recent exposure to tuberculosis? ❏ Yes ❏ No Any of the following symptoms: night sweats, cough with bloody sputum?11. Within the last two weeks have you had any exposure to chicken pox, mumps, measles (rubeola), German measles (rubella)? 12. Do you have any ❏ physical disabilities, ❏ back pain, ❏ arthritis or ❏ bursitis?13. Do you have sleep apnea? C-PAP? Sleeping disorders? Snoring? ❏ Yes ❏ No 14. Any other medical conditions? List: ____________________________________________________________________15. Do you have any implants? ❏ Yes ❏ No (Cardiac, Cosmetic, Orthopedic) List: _________________________________16. Have you ever had motion sickness?❏ Yes ❏ No 17. Do you smoke? ❏ Yes ❏ No How much/day? _________________________________________________________18. Do you drink alcoholic beverages? ❏ Yes ❏ No How much/week? _________________________________________19. Do you use recreational drugs? ❏ Yes ❏ No Please list __________________________________________________20. Do you have any ❏ loose teeth, ❏ dentures, ❏ permanent or removable bridges or ❏ front capped teeth?21. Do you wear contacts? ❏ Yes ❏ No 22. Do you have any difficulty opening your mouth? ❏ Yes ❏ No 23. Have you or any blood relative had an unusual reaction to anesthesia or malignant hyperthermia? ❏ Yes ❏ No 24. Are you allergic to anything? ❏ Yes ❏ No List: __________________________________________________________25. Do you have a latex allergy? ❏ Yes ❏ No 26. Do you currently take any medications ? ❏ Yes ❏ No27. Within the last year have you had cortisone or steroids? ❏ Yes ❏ No 28. Within the last two weeks have you taken ( Check ) ❏ a tranquilizer, ❏ diet pills or ❏ herbal medications? ❏ Yes ❏ No 29. Have you taken any medication today? ❏ Yes ❏ No List: __________________________________________________30. Do you use aspirin, ibuprophen (Motrin), Advil, Aleve, Naproxen or Anaprox? ❏ Yes ❏ No Others ______________________________________ Last date taken? ______________________________________ 31. Do you use blood thinners (Heparin, Lovenox, Coumadin, etc.)? ❏ Yes ❏ No Last date taken?____________________32. Do you have bleeding tendencies? ❏ Yes ❏ No 33. Could you be pregnant at this time? ❏ Yes ❏ No Date of last menstrual period: ________________________________34. Circle pain medications you have ever taken: | Tylenol | Percocet | Codeine | Aspirin | Darvocet | Vicodin | Other35. Height: _________________ Weight: ________________ (i.e. fever, nausea, vomiting, low blood pressure) COMPLETED BY: ______________________________________________ RELATIONSHIP: __________________________________________ DATE: _____________________________________REVIEWED BY: PRE-OP RN: _______________________________OR R.N.: _____________________________________ 450 North Roxbury Drive #520 | Beverly Hills | CA 90210 | 310-246-4628 |


Feeling better – Lifestyle management for chronic mental disorders In this module we have learned about three risk factors associated with poor physical health: overweight, lack of physical activity and smoking. All three factors are more common in patients with chronic mental disorders than in the general population and may be associated with a tangible reduction of life expectancy.

PRIOR AUTHORIZATION REQUEST FORM Risperdal Consta® (Risperidone)r rPhone: 215-991-4300 r Fax back to: 866-240-3712 r HEALTH PARTNERS manages the pharmacy drug benefit for your patient. Certain requests for coverage require review with the prescribing physician. Please answer the following questions and fax this form to the number listed above. Please print clearly. Patient Name:

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