Anemia AsthmaArtery Disease Osteoarthritis Rheumatoid Bronchitis CholecystitisChronic Obstructive Pulmonary ArthritisDisease Cirrhosis Congestive Heart Failure Coronary Depression Diabetes, Type 1 Diabetes, Type 2 Disease Diverticular Emphysema Glaucoma Gout Hemophilia Hernia Hypertension Irritable Bowel Syndrome Multiple Osteoporosis Parkinson’s Psoriasis Sclerosis Disease Renal Failure Seizure Disorder Thyroid Disease Venous Insufficiency Vision DisturbanceOther (describe): Current medical conditions/Chronic illnesses (check all that apply) Female:
Dysfunctional Fibrocystic Premenstrual Uterine Bleeding Breast Disease Syndrome Male: Prostate Disease Current medications (include prescription, over-the-counter, herbs, and vitamins): Name of Drug Dosage/Frequency Last Dose Taken Reason for taking Ventolin INH 2 puffs PRN 3 years ago Asthma Multivitamin 1 tab 10/04/2013 Supplement Allergies to Medication/Foods/Medical Products/Other (e. g. , latex, contrast, tape): Allergic To Type of Reaction PCN Hives, difficulty breathing Current medical treatments (e. g. , breathing treatments, dialysis, wound dressing): Past Health History.
Name and Type Date / Year Residual Problems Previous Medical Conditions or Problems NIDDM Asthma 03/2000 1982 Diet controlled Requires rescue inhaler PRN Previous Hospitalizations Surgeries Wisdom teeth extraction under IV sedation 2005 Serious Injuries Immunizations: Immunization Date/s Immunization Date/s Diphtheria 02/2009 Pertussis 02/2009 Tetanus 02/2009 Inactivated poliomyelitis (IPV) Haemophilus influenza type b (Hib) 09/2012 Hepatitis B 02/2009 Meningococcal conjugate vaccine (MCV) Rotovirus Last examinations: Last Examination Date Outcome Last Physical 04/2012 Good. A1C 5.
0 Last Vision 09/2013 Normal Last Dental 2012 Couple of caries fixed Other (Describe) Women Only Last Menstrual Period Last Pregnancy Last Pap Smear Last Mammogram Family History (Indicate age and current health. If deceased, indicate age and cause of death. ) Person Age Current Health (A&W = alive and well Deceased , Chronic Problem (describe) Unk = Unknown Mother 57 Asthma, arthritis (A) (C) Father 78 Renal cell carcinoma (D) Maternal Grandmother 82 Macular degeneration (A) (c) Maternal Grandfather HTN, Parkinson’s (D) Paternal Grandmother Diabetes (D) Paternal Grandfather.
Unk (D) Maternal Aunts / Uncles Unk Paternal Aunts / Uncles Unk Sister 1 Sister 2 Sister 3 Brother 1 37 None Brother 2 Brother 3 Other (describe) Personal and Psychosocial History Family/Social Relationships (significant others, individuals in home, role within family, etc. ) Diet/Nutrition (include appetite, typical food intake, etc. ) Functional Ability (indicate ability to independently perform following self-care activities*): ACTIVITY Perform Independently (yes or no) Challenges (describe).
Dressing yes Toileting yes Bathing yes Eating yes Ambulating yes Shopping yes Cooking yes Housekeeping yes Mental Health (anxiety, depression, irritability, stressful events, personal coping strategies) Personal Habits Y/N Describe if yes Tobacco use: N______________________________________ Alcohol intake: N________________________________________ Illicit drug use: N_________________________________________ Health Promotion Y____________________________________________ Exercise (type/frequency): Self-examination (type/frequency): Oral hygiene practice (frequency of brushing/flossing): Screening examinations (blood pressure, prostate, breast, glucose, etc. ):
Environment (including living and work environment) Review of Systems (check all symptoms that apply, and comment below) General Symptoms: PainFatigue Weakness Fever Problems Unexplained Sleeping Changes in weight Comments: Integumentary System: Change in skin Excessive Itching Skin lesions color/texture bruising Sores that do not Change in mole Recent hair loss Change in nails or heal or hair texture Do you use sunscreen? Yes How much sun exposure do you experience? Comments: Head: Headache Head injury Dizziness Fainting Spells Comments: Eyes: Change in vision Discharge Excessive tearing Eye Pain.
Sensitivity to Flashing lights Halos around Difficulty reading light lights Wear corrective If yes: how long? Last date evaluated lenses Comments: Ears: Ear pain Drainage Recurrent infections Excessive ear wax Changes in Ringing in ears Sensitivity to noises hearing Comments: Nose, Nasopharynx, Sinuses: Nasal discharge Frequent nosebleeds Sneezing Nasal obstruction Sinus pain Postnasal drip Change in smell Snoring Comments: Mouth/Oropharynx: Sore throat Sore in mouth Bleeding gums Change in taste Trouble Trouble Dental Change in voice chewing swallowing prosthesis Comments: Neck:
Lymph node Swelling or mass Neck pain Neck stiffness enlargement in neck Comments: Breasts: Pain Swelling Lumps or masses Change in appearance Nipple discharge Do you perform breast self-examinations? If yes: How often? Comments: Respiratory System: Frequent colds Shortness of Wheezing Pain with breathing breath Cough Coughing up blood Night sweats Comments: Cardiovascular System: Chest pain Palpitations Dyspnea Edema Coldness to Discoloration Varicose veins Leg pain with activity extremities Parasthesia Comments: Gastrointestinal System: Pain Heartburn Nausea/vomiting Vomiting blood.
Jaundice Change in Diarrhea Constipation appetite Change in bowel habits Comments: Urinary System: Hesitancy Frequency Change in stream Nocturia Pain with Flank pain Blood in urine Excessive urinary urination volume Decreased urinary volume Comments: Reproductive System: Lesions Discharge Pain or masses Females: Pain during Heavy or prolonged No menses menses menses Are you currently involved in a sexual relationship(s)? YesNo If yes, what is the nature of the relationship(s) (heterosexual, homosexual, bisexual)? Number of sexual partners in last 3 months? Do you protect yourself from sexually transmitted disease (STD)?
YesNo If yes, method(s) used: Do you use birth control? YesNo If yes, method(s) used: Problems with sexual activity: Painful intercourse Change in sex drive Infertility Impotence Comments: Musculoskeletal System: Muscle pain Weakness Joint swelling Joint pain Stiffness Limitations in Limitations in Back pain range of motion mobility Comments: Neurologic System: Pain Seizures Fainting Changes in cognition Changes in Problems with Tremor Spasms memory coordination Comments: Include: Nutrition assessment, Sleep evaluation, and a Mini-Cog (Mini Cog only if age 65 or older).