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    AK022IBD

    Uploaded by

    Benoit-Vincent Beainy
    This document is a patient information form for inflammatory bowel diseases from the Ministry of Public Health in Lebanon. It requests medical information about the patient's condition, including prior treatments, test results, and physician details. It serves to document a new or renewal application for treatment. The form must be completed by the treating doctor and include attachments of identification, medical reports, prescriptions, risk assessments, and lab or imaging results. All attached information should be original and official.

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    AK022IBD

    Uploaded by

    Benoit-Vincent Beainy
    32 views1 page
    This document is a patient information form for inflammatory bowel diseases from the Ministry of Public Health in Lebanon. It requests medical information about the patient's condition, including prior treatments, test results, and physician details. It serves to document a new or renewal application for treatment. The form must be completed by the treating doctor and include attachments of identification, medical reports, prescriptions, risk assessments, and lab or imaging results. All attached information should be original and official.

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    © © All Rights Reserved

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    This document is a patient information form for inflammatory bowel diseases from the Ministry of Public Health in Lebanon. It requests medical information about the patient's condition, including prior treatments, test results, and physician details. It serves to document a new or renewal application for treatment. The form must be completed by the treating doctor and include attachments of identification, medical reports, prescriptions, risk assessments, and lab or imaging results. All attached information should be original and official.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    32 views1 page

    AK022IBD

    Uploaded by

    Benoit-Vincent Beainy
    This document is a patient information form for inflammatory bowel diseases from the Ministry of Public Health in Lebanon. It requests medical information about the patient's condition, including prior treatments, test results, and physician details. It serves to document a new or renewal application for treatment. The form must be completed by the treating doctor and include attachments of identification, medical reports, prescriptions, risk assessments, and lab or imaging results. All attached information should be original and official.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
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    AK/022/IBD

    Reepublic of
    o Leban
    non ‫ﺠﻤﻬﻮرﻳـﺔ ااﻟﻠﺒﻨﺎﻧﻴـﺔ‬
    ‫اﻟﺠ‬
    Miinistry of Public
    P Healtth ‫وززارة اﻟﺼﺤـﺔ اﻟﻌﺎﻣـﺔ‬

     
     
    In
    nflammaatory Bow
    wel Diseaases 
    ™ Patientt Informattion 
    ................................. : ‫ﻄﺎﻗﺔ اﻟﻜﺮﻧﺘﻴﻨﺎ‬
    ‫رﻗﻢ ﺑﻄ‬ ....................................... : ‫رﻗﻢ اﻟﻟﻬﻮﻳﺔ‬
    ---------------------------- :‫ ااﻟﺸﻬﺮة‬-------------------------- :‫ اﺳﻢ اﻷب‬--------------------- :‫اﺳﻢ اﻟﻟﻤﺮﻳﺾ‬
    ‫ﻰ‬
    ‫اﻧﺜﻰ‬ ‫ذآﺮ‬ --------/----/------ :‫ ﺗﺎررﻳﺦ اﻟﻮﻻدة‬-------------------- :‫ﻻم‬
    ‫اﺳﻢ اﻻ‬
    ‫اﻟﻌﻨﻮان‬
    ------------------------- : ‫ اﻟﺒﻠﺪة‬---------------------- : ‫ اﻟﻘﻟﻘﻀﺎء‬------------------ : ‫اﻟﻤﺤﺎﻓﻓﻈﺔ‬
    ----/--------------- : ‫ هﺎﺗﻒ‬------------------------- : ‫ﻚ‬
    ‫ ﻣﻠﻚ‬----------------- : ‫اﻟﺸﺎرع‬
    ‫ع‬
    ™ Medicaal Informaation  
                           New application n                            Renew
    wal 
    Height: ……………cm                       Weeight: ………….Kg  ICD‐10 Speecific Diagno
    osis: 
    Prior treatm
    ment and / or current immunosu
    uppressant ((if applicab
    ble): 
       Drug                      Dosse                        Period (from ‐ to)                   R
    Response                 Side
    e effects 
    ………….. ……
    ………… ….
    ………………… ……………… ……
    …………
    ………….. ……
    ………… …………………
    … ……………… …………
    ……
    ™ Physician Inform
    mation  
    Physician
    n name: ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐   LOP
    P Registratio
    on No:  ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐ 
    Specialtyy:  ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐     Teleephone:  ‐‐‐‐‐/‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐ 
    Date:  ‐‐‐‐‐ / ‐‐‐‐ / ‐‐‐‐‐‐‐‐‐‐‐                                           Sign
    nature & Staamp: 

    ™ Docum
    ments to be
    e submitted: 
    1. ‫ﺻﻮرة اﻟﻬﻬﻮﻳﺔ او اﺧﺮاج اﻟﻘﻴﺪ‬
    2. Detailed Mediccal report ‫اﻟﻄﺒﻴﺐ‬‫ﺐ‬ ‫ﺗﻘﺮﻳﺮ‬
    3. Phyysician’s preescription ‫ اﻟﻮﺻﻔﺔ اﻟﻄﺒﻴﻴﺔ‬ 
    4. Reactivation rissk: HBs Ag, HCV Ab, PP PD, Chest X‐‐Ray 
    5. Basic Labs: CBC C, plts, LFTs (ALT & ASTT), CRP … 
    6. Colo onoscopy & & Pathology Result 
    7. Imaging if availlable (CT scan, MRI, …)) 
    8. (‫ﻷدوﻳﺔ )اذا وﺟﺪﺪت‬‫ ﺻﻮﻮرة ﻋﻦ ﺑﻄﺎﻗﺔ ﻣﻣﺮآﺰ ﺗﻮزﻳﻊ اﻷ‬ 
    N.B: 
    1. This form mmust be comppleted by the d
    doctor 
    2. All informaa on should b
    be a ached 
    3. All a ached reports and studies should be original and official 

    www ges/MPH12-1.aspx
    w.moph.gov.lbb/Services/Pag 1 Page 1 of 1 d
    drugs@mop
    ph.gov.lb

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