Are you having any problems or symptoms today that you would like to discuss? q yes q no
If you answered yes, please briefly explain:
Are you allergic to any medicines or foods? q yes q no
If you answered yes, please list what medicines or foods you are allergic to and your reaction to each:
Current medications (Prescription / Over the counter): q None q Multivitamins q Folic Acid q Calcium q Birth Control
q Other:
Have you had any hospitalizations, major injuries, or surgeries? q yes q no
If you answered yes, please briefly explain:
Living Conditions: q Alone q With family: # of children in home______q With Roommate q In group or foster home
Marital Status: q Single q Married q Divorced q Widowed
Education: q Not a student.
Highest education level completed: ______
q Current Student: School ______Grade______/ Employment: q Not employed
q Currently employed: Where? ______
Please check if you have or have had any of the following: q NO CURRENT COMPLAINTS
CONSTITUTIONAL HEAD, FACE, NECK CARDIOVASCULAR RESPIRATORY
q Fatigue q Headaches q Angina or heart attack qAsthma or Wheezing
q Difficulty sleeping q Reduced facial strength q Chest pain or pressure q Difficulty breathing
q Fever/chills q Recent hair loss q Fast or irregular heart beat q Cough with mucous production
q Night sweats q Scalp tenderness q Swelling of feet / ankles q Chronic or frequent coughs
q Recent weight change q Swollen glands in the neck q Poor circulation q Dry cough
q Blood clots q Pain on breathing
EYES CHEST/BREAST q High blood pressure q Spitting/coughing blood
qBlurred or double vision q Breast discharge
qDryness / Redness q Breast lump GENITOURINARY MUSULOSKELETAL
q Wear glasses or contacts q Breast pain q Burning or painful urination q Back pain
q Cataracts q Breast implants q Blood or pus in urine q Cold extremities
q Glaucoma q Incontinence or dribbling q Numbness or tingling
GASTROINTESTINAL q Vaginal discharge q Paralysis
EARS/NOSE/MOUTH/THROAT q Heartburn or indigestion q Irregular periods q Joint pain
qEaraches or drainage q Loss of appetite q Painful periods q Joint stiffness or swelling
qRinging in the ears q Abdominal pain q Prostate problems q Weakness of muscles or joints
qHearing loss q Changes in bowel habits q Testicular pain q Walk with assistive device
qSinus infections/problems q Painful bowel movements q Sexual difficulty q Difficulty climbing stairs
qNosebleeds q Constipation q Genital rash or ulcers
qFrequent sore throat q Frequent diarrhea NEUROLOGICAL / PSYCHIATRIC
qDryness of the mouth q Hemorrhoids/blood in stool SKIN qConvulsions or seizures
qBad breath/bad taste q Nausea or vomiting q Rash or itching qTremors
qMouth sores/ulcers q Abnormal liver tests/ liver disease q Change in moles qMemory loss or confusion
qVoice changes q Change in skin color qLight headed/ Dizziness
qBleeding gums ENDOCRINE q Psoriasis qLoss of consciousness
qDifficulty swallowing q Diabetes q Skin nodules or bumps qStroke
qDentures q Thyroid disease q Easy bruising q Depression
q Excessive thirst q Sores that won’t heal
q Change in tolerance to hot/cold weather
Please P those that apply to you or your blood relatives.
You (Patient) / Father / Mother / Brother / Sister / Grandparent / Child
HIV/AIDS
Alcohol / Drug Addiction
Alzheimer’s
Arthritis
Asthma
Birth Defects
Bleeding Disorder / Free Bleeder
Cancer
COPD / Emphysema / Chronic Bronchitis
Diabetes
Epilepsy / Convulsions / Seizures
Heart Attack / Stroke
High Blood Pressure
High Cholesterol
Kidney Disease
Liver Disease / Hepatitis
Mental Illness / Depression
Osteoporosis
Sickle Cell
Thyroid Disorder
Tuberculosis/TB
Other:
Please P or describe all that apply.
Nutrition: check foods you eat every day
qMilk / Dairy qMeats qVegetables
qFruits qBreads or Grains / Do you have concerns about your weight? qYes qNo / Exercise
q None q Seldom
q Occasional q Frequent
Tobacco Use / Smoke Exposure
q Never used q Exposed to smoke
q Past user: type ______
qUse now: type ______
(# per day _____) / Alcohol
qNone
qSeldom: type ______qOccasional: type ______
qFrequent: type ______/ Street Drugs
qNone
qSeldom: type ______
qOccasional: type ______
qFrequent: type ______/ Mental Health: (in past 90 days)
q No Problem
q Mild/Moderate Depression
q Severe Depression
qThoughts of harming self / others
Dental Health
qBrush daily qFloss daily
qVisit dentist every 6 months / Water Source:
q Well q Cistern
q Bottled q City / Travel: qNo travel outside USA qTraveled outside USA: Country/Year______/_____
Abuse / Neglect / Violence:
q No fear of harm qPressure to have sex
qDaily needs not met qForced sexual contact
qFear of verbal/physical abuse
qSex for money or drugs / Sexually Active: qYes qNo / Females only: Do you examine your breasts every month? qYes qNo
First day of last menstrual period:___/___/___
Males only: Do you examine your testicles every month?
qYes qNo
Patient Signature: Healthcare Provider Signature: Date:
TO BE COMPLETED BY HEALTHCARE PROVIDER
FEMALES ONLY / MALES ONLY
Age of menarche:
# Days between periods: # Days of bleeding:
Problems with menses: q yes q no
Describe: / # living children:
Fertility problems: q yes q no
Describe:
Hx of testicular biopsy: q yes q no
Date / Year:
Result:
Age at first pregnancy:
G Para SAB ETP
# living children:
PSA testing: q yes q no
Most recent date / year:
Result:
Hx of NTD: q yes q no
Age at last pregnancy:
Date of last delivery:
Hx of abnl PSA: q yes q no
Date / Year:
Result:
Fertility problems: q yes q no
Describe:
Currently using contraception: q yes q no
Type: / Digital rectal exams: q yes q no
Most recent date / year:
Result:
Interruption in B/C method? q yes q no Describe:
Menopausal symptoms: q yes q no
Describe: / Hx of abnl digital rectal exam: q yes q no
Date / Year:
Result:
HRT: q yes q no
Type:
Sigmoidoscopy: q yes q no
Date / Year:
Result:
Age at final menses:
Rubella status: q immune q unknown
DES Exposure: q yes q no q unknown / FOBT: q yes q no Year:
Result: q pos q neg
Routine Pap Tests: q yes q no
Most recent date / Year: Result:
Colonoscopy: q yes q no Year:
Result:
Hx of abnl pap / HPV: q yes q no
Date / Year: Result:
SEXUAL HISTORY
Hx of colposcopy/biopsy:q yes q no
Date / Year: Result: / Sexual partners: q men q women q both
# Sexual partners: lifetime_____ last year_____
last 60 days _____ last 30 days _____
Mother,sister,daughter with breast cancer < age 50? q yes q no
Currently breastfeeding:q yes q no
Ever breastfed: q yes q no / Sex with anonymous partners: q yes q no
First sexual contact <18 yrs of age: q yes q no
Routine Mammograms: q yes q no
Most recent date / Year: Result: / Bleeding, spotting, pain with intercourse: q yes q no
Describe:
Hx of abnl mammogram / CBE: q yes q no
Date / Year: Result: / Condoms used routinely: q yes q no
Hx of STDs: q yes q no
Hx of 2 STDs: q yes q no
Disease(s):
Hx of breast biopsy: q yes q no
Date / Year: Result:
FOBT: q yes q no Year: Result: q pos q neg / HIV tested: q yes q no
Most recent date:
Result: q pos q neg
Unprotected sex since last test: q yes q no
Colonoscopy: q yes q no Year: Result:
Immunization Status: q Up to date by patient report q Records Requested
q See Vaccine Administration Record q Vaccines given today / Lead Assessment: Verbal Risk Assessment:q neg q pos qN/A
Tested Today: q yes q no Referred for testing: q yes q no
Preventive Health Education: topics discussed today
q Child development q Physical activity q Preconception /Folic Acid q Pelvic / Pap
q Immunizations q Safety q Prenatal / Genetics q SBE /Mammogram
q Dental q Mental Health q CVD q STE / PSA
q Hearing/Vision q DV/SA q Arthritis q HRT
q Lead exposure (ACH-25a) q ATOD / Cessation / SHS q Osteoporosis q STD / HIV
q Diet / Nutrition q Diabetes q Cancer q Family planning
q MINOR Family Planning: Sexual coercion. Abstinence. Benefits of parental involvement. q Options Counseling / Educational Handouts:
q FPEM q PTEM q CSEM
q Other:
Patient verbalizes understanding of education given q
Healthcare Provider Signature: Date:
SUBJECTIVE / PRESENTING PROBLEM:
OBJECTIVE: General Multi-System Examination
SYSTEM / NL / ABNORMAL / SYSTEM / NL / ABNORMAL
Constitutional / General appearance / Lymphatic / Neck,Axilla,Groin AC
Nutritional status / Musculoskeletal / Spine
Vital signs / ROM
HEENT / Head: Fontanels, Scalp / Symmetry
Eyes: PERRL / Skin / SQ Tissue / Inspection(rashes)
Conjunctivae, lids / Palpation (nodules)
Ear: Canals, Drums / Neurological / Reflexes
Hearing / Sensation
Nose: Mucosa/ Septum / Psychiatric / Orientation
Mouth: Lips, Palate / Mood / Affect
Teeth, Gums / EXPLANATION OF ABNORMAL FINDINGS:
Throat: Tonsils
Neck / Overall appearance
Thyroid
Respiratory / Respiratory effort
Lungs
Cardiovascular / Heart
Femoral/Pedal pulses
Extremities
Chest / Thorax
Nipples
Breasts
Gastrointestinal / Abdomen / Tanner Stage: q typical q atypical
Liver / Spleen
Anus / Perineum /
X-Ray: Type: Result:
Date taken: qNo Change
Date read: qNeg/Non-remarkable
Date compared with: qImproved
qWorsening
Genitourinary / Male: ScrotumTestes
Penis
Prostate
Female:Genitalia / TB Classification: q TB suspect
q0 No TB exposure, not infected
qI TB exposure, no evidence of infection
qII TB infection, without disease
qIII TB, clinically active
qIV TB, not clinically active
Site of infection: qPulmonary __Cavity __Non Cavity q Other:
Vagina
Cervix
Uterus
Adnexa
ASSESSMENT:
PLAN:
Testing today: q N/A
q GC q Chlamydia
q UA q TST
q VDRL q HIV
q Pap qLead
q Hgb q Cholesterol
q Blood Glucose
q Urine PT / UCG: q+ q- Planned? q Yes q No
qWet Mount
qOther: / Medications/Supplies:
q N/A
q MV / Folic Acid
Number of bottles given_____
q Birth Control Method given:______
q Foam Issued (#) ______
q Condoms Issued (#) ______
q Foam/Condoms offered;
pt. declined
q Other: / Recommendations made to client, for scheduling of follow-up testing and procedures, based on assessment: q N/A
q Vision q Hearing q FBS /GTT
q Dental q Lipid Screen q Hgb
q Pap Smear q Sickle Cell q Lead
q Mammogram q Ultrasound q UCG/HCG q TST / CXR
qBone Density q Liver Panel
qBlood Glucose q Colorectal Scr.
qOvarian Cancer Scr q Other: / Referrals made: q N/A
q PMD q HANDS
q Pediatrician q WIC
q Specialist: q FP
q Radiology
q MNT with RD
q Medicaid
q Social Services
q 1-800-QUIT-NOW
q Cooper Clayton Classes
q Other:
Healthcare Provider Signature: Date: Recommended RTC:
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