Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Download BASELINE PATIENT INFORMATION FORM
Document related concepts
Transcript
BASELINE PATIENT INFORMATION FORM PATIENT NAME __________________________________________________________________ AGE CHIEF COMPLAINT: Why have you come to see the doctor today? PAST MEDICAL HISTORY: Have you had any health problems in the past? YES NO them noting each problem and the date. If yes, list _______________________________________________________ __________________________ _______________________________________________________ __________________________ _______________________________________________________ __________________________ Please list all medications you take. Please write amount and how often you take the medicine. ___________________________ _________________________ __________________________ ___________________________ _________________________ __________________________ Are you allergic to any medications? YES NO If yes, please list the medications. ___________________________ _________________________ __________________________ Please list any hospitalizations or surgeries you have had in the past. YEAR HOSPITAL REASON DOCTOR _______ __________________ _______________________________ __________________ _______ __________________ _______________________________ __________________ Please check any of the listed medical problems (current or in the past) High Blood Pressure Stomach Ulcers Rheumatoid Arthritis Sinus Infections YES YES YES YES NO NO NO NO Blood Problems Heart Disease Lung Disease Skin Disorders YES YES YES YES NO NO NO NO Kidney Disease Tuberculosis Liver Disease Thyroid Disease YES YES YES YES NO NO NO NO Stroke Lupus Diabetes Cancer YES YES YES YES NO NO NO NO SOCIAL HISTORY: What type of work do you do?__________________________________________ Have you ever smoked? YES NO If yes, ______packs per day. How many years? _____________ If you have stopped, when was the last time you smoked? ______________________________ Do you currently drink alcohol? YES NO If yes, how much? ______________________________ If you no longer drink alcohol please note the date. ______________________________ Please circle your marital status: SINGLE MARRIED DIVORCED WIDOWED Do you live alone, with someone else, or in a group setting such as a nursing home? ________________________________________________________________________________________ FAMILY HISTORY: Is there anyone in your family who has had similar health problems? YES If yes, list the medical problem and the family member who had it. _________________________________ _________________________________ ___________________________________________ ___________________________________________ NO REVIEW OF SYMPTOMS Do you NOW have or have you RECENTLY had any of the following symptoms or problems? YES NO YES NO YES NO Constitutional Tiredness Night Sweats Fever ______ ______ ______ ______ ______ ______ Easy Fatigue Weight Loss Joint Pain ______ ______ ______ ______ ______ ______ Muscle Soreness _____ Pain when combing hair _____ Swollen Glands ______ _______ ______ _______ ______ Pacemaker ______ ______ Ankle Swelling Shortness of breath when climbing stairs or with work _____ _____ _____ Cardiovascular Asthma Pneumonia Gastrointestinal Sore Throat _______ _______ Difficulty Swallowing ____ _______ _ Musculoskeletal Muscle Pain ______ ______ _____ ________ _____ _______ Heartburn Diarrhea ______ ______ ______ ______ Constipation ______ _______ Black Tarry Stool ______ _______ Limb Weakness ______ ______ Arthritis ______ _______ Jaundice ______ ______ Skin Skin Rash ______ ______ Skin Lesions ______ Neurological Dizziness Numbness ______ ______ ______ ______ Weakness Tingling ______ ______ ______ ______ Psychiatric Anxious Hallucinations ______ ______ ______ ______ Depressed ______ ______ Difficulty Sleeping _____ ______ Trouble Starting Stream _____ _____ Pain when urinating _____ ______ Increased Frequency____ ______ ______ ______ Sensitive to Heat Sensitive to Cold _____ _______ ______ ______ Get Infections Easily ______ _______ Urologic Blood in Urine ______ ______ Kidney Infection ______ ______ Endocrine Extreme Thirst _ Hematological Easy Bruising ______ ______ ______ Decreased Concentration _____ _______ Headache _____ _______ Nose Bleeds Patient miscellaneous comments _______________________________________ Patient Signature ___________________________ Date ______ ______
