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TSWF-Core Encounter (ARMY FACILITIES ONLY) Worksheet with SF600 Version: May-Aug 2016 **Please complete ALL shaded areas. Complete other areas if this is your first visit or for any changes.** Patient Name: Rank: (Active Duty Only) DoD ID #: A. What is the reason for today’s visit? ___________________________________________________________________ B.How long have you had this issue? _______________________ Please circle if this issue is getting better worse C. Please rate your pain level on a scale of 0 (no pain) to 10 (severe pain): # ___/10 D. With regard to pain, please indicate the following: Location:_______________ Duration: _____________ Quality:________________ Factors that correlate with onset:______________________________ Frequency:____________ Average level of pain:____________ Worst level: _______ Least level: ________ What makes it better:_____________________What makes it worse:__________________ K. Preventive Services: Please indicate the date E. Medical Conditions H. Allergies these services were completed: Do you have any of the following? (circle) High Blood pressure - High Cholesterol Diabetes - Asthma - Heart Disease Obesity - Cancer - Had a Heart Attack Other: Lipid Screening – 10yr CVD Risk AssessmentCalculator used- I. Current Medications PLEASE INCLUDE DOSAGE. IF YOU HAVE A LIST WITH YOU HAVE IT READY. (Include over-the-counter meds, Tylenol, vitamins, herbal supplements): F. Surgeries or Hospitalizations (dates) Tetanus (Td/Tdap) Influenza Vaccine Zoster Vaccine Pneumococcal Vaccine - PPSV23: HPV Vaccine – G. Family History HIGH BLOOD PRESSURE: HIGH CHOLESTEROL: DIABETES: HEART ATTACK: (who, age?) CANCER: (type, who, and what age when diagnosed?) Diabetes Screening Aspirin Prophylaxis - Yes No HIV Screen Colonoscopy – J. Social History Family/Occupation issues: Women: Cervical Cancer Screen - Pap: Mammogram Chlamydia Screen Osteoporosis Screen Folic Acid - Yes No PCV13: HPV: Men: Aortic Aneurysm Screen - OTHER: Yes No Do you engage in 150 minutes of moderate intensity exercise per week and muscle strengthening activities 2 or more days per week? (Anything that raises heart rate/causes sweat) Yes No Do you consume any alcohol? Yes Never Do you now or have you ever used tobacco products, including smokeless tobacco, e-cigs and vaping? If YES, check the following box that applies: I CURRENTLY USE Tobacco Products- What type? ___________ How much per day? _________Interested in quitting? Yes No I QUIT USING Tobacco Products When did you quit?________________________ Over the last 2 weeks, how often have you been bothered by any of the following problems? [0] Little interest or pleasure in doing things Feeling down, depressed, or hopeless Not at all Not at all [1] Several days Several days [2] More than half the days More than half the days [3] Nearly every day Nearly every day Over the last 2 weeks, how often have you been bothered by any of the following problems? [0] Feeling nervous, anxious or on edge Not being able to stop or control worrying Not at all Not at all [1] Several days Several days [2] More than half the days More than half the days [3] Nearly every day Nearly every day ACTIVE DUTY SOLDIERS ONLY: In your life, have you ever had any experience that was so frightening, horrible or upsetting that, in the past month, you: [ ] Yes [ ] No Have had nightmares about it or thought about it when you did not want to? [ ] Yes [ ] No Tried hard not to think about it or went out of your way to avoid situations that reminded you of it? [ ] Yes [ ] No Were constantly on guard, watchful, or easily startled? [ ] Yes [ ] No Felt numb or detached from others, activities, or your surroundings? Females Only: Yes No Could you be pregnant? Date of Last Period __________________ Unknown Yes No Are you currently in a situation where you are being verbally or physically hurt, threatened, or made to feel afraid? (Recommended for females ages 14-46) Would you say your general health is Excellent Very Good Good Fair Poor Yes No Since your last visit with us, have you had any medical care other than in this clinic? Yes No Is this visit deployment related? If yes, when and where was deployment: _________________________ Yes No Are you currently Active Duty? If yes, have you had a PHA in the last year? Yes No Date of PHA:______ What is your preferred language (written or spoken)? _______________________________ What is your preferred method for learning: Verbal Written Visual Other: _____________________ Yes No Do you have a learning disability, language barrier, hearing/vision deficit?___________________________ Yes No Do you have an advance directive? If yes, have you given a copy to your Primary Provider? Yes No Yes No Do you have any cultural or religious beliefs that may affect your care? Yes No Are you enrolled in EFMP (Exceptional Family Member Program)? Yes No Enrolled in Relay Health/Secure Messaging? E-mail address if no:________________________________ Yes No Special Duty? If yes check which applies PRP SCI PSP Flight status Dive status -----------------------------(This section NOT for patient use)---------------------------HEALTH CHRONOLOGICAL RECORD OF MEDICAL CARE DATE SYMPTOMS, DIAGNOSIS, TREATMENT, TREATING ORGANIZATION (Sign each entry) AHLTA was not accessible during this patient visit. Reviewed note & agree with the reverse side ____ (Provider Initial) VITALS: BP _________ Pulse _______ RR ______ Temp _______ Ht _______ Wt ______ O2Sat ______ SUBJECTIVE: OBJECTIVE: General Eyes Ears Nose/Throat Neck ROS: Fever Chills Recent Wt Loss WD WN NAD Headache Earache PERRL Sclera Conjunctiva Optic Disc Nasal Discharge Nasal Blockage Outer Ear TMs: Bulging Erythema Fluid Canal Mobility Throat Pain Left Chest Pain Right Cough Difficulty Breathing Nasal Mucosa Sinus Tenderness Oropharynx Appearance Tenderness Thyroid Carotid Bruit Lymph Node Enlargement Submandibular Cervical Supraclavicular Lungs CTA Wheezing Respiration Rhythm and Depth Rales Cardiovascular RRR S1/S2 NT Mass Rub Edema BS Decreased Liver Abdomen Male Genitalia Female Genitalia Rectal Breasts Skin Neuro Psych Musculoskeletal ASSESSMENT: PLAN: Mumur S3 ND Spleen Rhonchi Gallop PMI Displaced Abd Bruit Enlarged Inguinal Nodes Penis Testes Prostate Ext Genitalia Vagina Cervix IUD String visualized Uterus Adnexae CMT Hemorrhoids Sphincter Tone Rectum Rectal Mass Appearance Palpation Axillary Lymph Node Enlarged Lesions Bruising Temperature DTRs Balance Gait/Stance Monofilament Test Sensation Cerebellar CN II-XII Mood Affect Oriented x 3 Strength Muscles Tender Femoral Arterial Pulse Abnormal Movement of all Extremities Dorsalis Pedis Arterial Pulses Nausea Vomiting Abdominal Pain Rectal Bleeding Diarrhea Constipation Urinary Urgency Dysuria Urinary Frequency Back Pain Lightheadedness