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GENERAL CONFERENCE GRAND CHAPTERS, HOLY ROYAL ARCH MASONS
AND
GENERAL CONFERENCE GRAND COURTS, HEROINES OF JERICHO
OF THE UNITED STATES OF AMERICA AND THE BAHAMAS, INC., P.H.A.
PATIENT PROFILE
Telephone No._____________
NAME_______________________________
ADDRESS_________________________________________
CITY______________________________ STATE_____________ ZIP____________
CHAPTERI COURT__________________________ NO.______
PATIENT HISTORY
HTN____________ STROKE_________ DIABETES_______ HEART ATTACK_________
H. CHOL________OTHER________ MEDICATION_____________________
ALLERGIES: 1.________________ 2.___________________ 3.________________
FAMILY PHYSICAN:_____________________________________________________
CLINICAL DATA
PULSE:_____________ BP1._____ I______ 2._____/______ 3._____/_____
SUGAR_______________
PROTEIN______________
BLOOD _________________
PSA________________
OTHER_____________________:______________________________________________________________
IMPRESSION:
Physician’s Comments:
______________________
Physician’s Signature
To insure Patients privacy please return this completed for to Dr.Donald Ware , 54 W. 48th Los Angeles, CA 90043 no later than June 06, 2011.
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