Download TSWF Encounter Worksheet ARMY FACILITIES ONLY May Aug

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