|
Additional Complaint #2
|
Onset
|
|
Additional Complaint #3
|
Onset
|
|
HPI
|
Palliative/Provocative
|
|
Quality & Duration
|
Region/Radiation
|
|
Frequency
• • •
|
Time of Onset
|
|
Severity (Scale of 0 to 10)
• • •
|
|
|
Associated Symptoms
|
|
|
Review of Systems
|
|
|
Integumentary/Hair [-]
|
Integumentary/Hair [+]
• • •
|
|
|
Integumentary/Hair Additional Comments
|
|
Neurological [-]
|
Neurological [+]
• • •
|
|
|
Neurological Additional Comments
|
|
HEENT/Phlegm [-]
|
HEENT/Phlegm [+]
• • •
|
|
|
HEENT/Phlegm Additional Comments
|
|
Chest, CV, RESP [-]
|
Chest, CV, RESP [+]
• • •
|
|
|
Chest, CV, RESP Additional Comments
|
|
Back/Neck/Spine [-]
|
Back/Neck/Spine [+]
• • •
|
|
|
Back/NeckSpine Additional Comments
|
|
Upper MSK [-]
|
Upper MSK [+]
• • •
|
|
|
Upper MSK Additional Comments
|
|
Lower MSK [-]
|
Lower MSK [+]
• • •
|
|
|
Lower MSK Additional Comments
|
|
GI [-]
|
GI [+]
• • •
|
|
|
GI Additional Comments
|
|
Stool [-]
|
Stool [+]
• • •
|
|
|
Stool Additional Comments
|
|
GU [-]
|
GU [+]
• • •
|
|
|
GU Additional Comments
|
|
Psycological [-]
|
Psychological [+]
• • •
|
|
|
Psychological Additional Comments
|
|
Female Specific
|
|
|
Reproductive (Female) [-]
|
Reproductive (Female) [+]
• • •
|
|
|
Reproductive (Female) Additional Comments
|
|
|
|
|
Para:
|
Gravida:
|
|
Abortus:
|
Prematurity:
|
|
Menstrual Flow Description
• • •
|
Menstrual Flow Additional Comments
|
|
Male Specific
|
|
|
Reproductive Male (Male) [-]
|
Reproductive (Male) [+]
• • •
|
|
|
Reproductive (Male) Additional Comments
|
|
General Health
|
|
|
Energy Level Scale (0-10)
|
Stress Level Scale (0-10)
|
