Download Initial consultation

Name:
DOB:
Age:
Date:
INITIAL CONSULTATION
Problem List:
Timothy Schwaiger, NMD 8010 E. McDowell Rd., Scottsdale AZ 85257 • (480) 970-0000
Name:
DOB:
Age:
Date:
PMH:
Surgeries:
Medications:
Supplements:
Allergies:
Social History:
FH:
Alive
Died
Age
Health
F:
M:
MGF:
PGF:
MGM:
PGM:
Siblings:
Timothy Schwaiger, NMD 8010 E. McDowell Rd., Scottsdale AZ 85257 • (480) 970-0000
Name:
DOB:
Age:
Date:
Review of Systems (Check positive findings and chart below each section)
weight gain
weight loss
fatigue
fever
sweats
snoring
hypersomnolence
restless legs
hot
night sweats
chills
difficulty initiating sleep
Bedtime:
p.m.
Wake:
a.m.
Number of times wake during night:
Total Sleep Time:
Positive Findings:
Skin
Positive Findings:
HEENT
cephalalgia
head injury
migraines
diplopia
blurriness
cataracts
vision changes
discharge
hearing changes
tinnitus
sinusitis
decreased smell
rhinorrhea
epistaxis
tenderness or lesions (oral)
sore throat
hoarseness
dysphagia
swelling
pain
asthma
bronchitis
chronic cough
hemoptysis
SOB
tachypnea
Positive Findings:
NECK
stiffness
Positive Findings:
CHEST
Positive Findings:
CARDIOVASCULAR
Timothy Schwaiger, NMD 8010 E. McDowell Rd., Scottsdale AZ 85257 • (480) 970-0000
Name:
DOB:
Age:
Date:
angina
CHF
claudication
CVA
CAD
cyanosis
dizziness
DOE
hypertension
orthopnea
PND
phlebitis
constipation
diarrhea
melena
gallbladder issues
hematemesis
nausea
vomiting
hematochezia
hemorrhoids
indigestion
jaundice
rectal bleeding
anuria
dysuria
hematuria
polyuria
nocturia
discharge
frequency
hesitancy
incontinence
UTI
STD
Positive Findings:
GASTROINTESTINAL
Positive Findings:
GENITOURINARY
Positive Findings:
Males
Last DRE:
PSA:
Positive Findings:
Timothy Schwaiger, NMD 8010 E. McDowell Rd., Scottsdale AZ 85257 • (480) 970-0000
Name:
DOB:
Age:
Date:
NEUROMUSCULAR
anathesias
parasthesias
arthralgias
myalgia
nervousness
anxiety
syncope
vertigo
weakness
heat intolerance
cold intolerance
polydipsia
polyphagia
anemia
excessive bruising
bleeding
diabetes
thyroid problems
Positive Findings:
ENDOCRINE
Positive Findings:
Screening
Colonoscopy
Mammogram
DEXA
EGD
Imaging
Other:
Positive Findings:
General Energy:
0
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9
Exercise:
Type:
Frequency:
Restrictions:
Timothy Schwaiger, NMD 8010 E. McDowell Rd., Scottsdale AZ 85257 • (480) 970-0000
10
Name:
DOB:
Age:
Date:
DIET (24-Hour):
Breakfast
Lunch
Dinner
Snacks
Fluid Intake
Timothy Schwaiger, NMD 8010 E. McDowell Rd., Scottsdale AZ 85257 • (480) 970-0000
Name:
DOB:
Age:
Date:
OBJECTIVE:
BP:
P
RR
Ht
Wt
BMI
Abnormal Findings
Exam
Appearance
Eyes/ears/nose/throat
Hearing
Lymph nodes
Heart
Pulses
Lungs
Abdomen
Musculoskeletal
Neurological
Skin
TCM:
Right Pulse (Quality)
Left Pulse (Quality)
Tongue Body:
Tongue Coating:
Timothy Schwaiger, NMD 8010 E. McDowell Rd., Scottsdale AZ 85257 • (480) 970-0000
Name:
DOB:
Age:
Date:
Pain:
Numerical Pain Scale (To Be Circled by Patient)
0
1
No Pain = 0
2
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9
10
Worst Pain Imaginable = 10
Timothy Schwaiger, NMD 8010 E. McDowell Rd., Scottsdale AZ 85257 • (480) 970-0000
Name:
DOB:
Age:
Date:
ASSESSMENT:
ICD-9 Code
PLAN:
See Treatment Sheet
Timothy Schwaiger, NMD 8010 E. McDowell Rd., Scottsdale AZ 85257 • (480) 970-0000
Name:
DOB:
SUPPLEMENT/DOSE
Age:
Date:
INSTRUCTIONS
Diet and Lifestyle
Suggestions
_____________________________________
Timothy Schwaiger, NMD
Timothy Schwaiger, NMD 8010 E. McDowell Rd., Scottsdale AZ 85257 • (480) 970-0000