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Vital signs
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O2 Saturation
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Weight
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Height
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BMI
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RR
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HR
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Temperature
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Reason for visit
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What is your reason for the visit today?
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Health Goals
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Perceived Health Score
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Health Goals
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Other Goals (intellectual,social,spiritual)
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Current Providers and Suppliers
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PCP
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Specialist
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Allied Health
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Alternative providers
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Social history
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Current and past occupation
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Social Support
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Number of Confidantes
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Names of Confidantes
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Drug and Alcohol
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Advanced Directive?
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ADL and Functional Screening
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Bowels
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Bladder
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Grooming
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Toilet Use
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Feeding
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Transfer
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Mobility
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Dressing
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Stairs
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Bathing
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SCORE
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Stress and Mental Health
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In the last month, how often have you felt that you were unable to control the important things in your life?
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In the last month, how often have you felt confident about your ability to handle your personal problems?
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In the last month, how often have you felt that things were going your way?
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In the last month, how often have you felt difficulties were piling up so high that you could not overcome them?
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Stress level- how stressed is the patient right now?
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New Field
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Depression Screening
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Little interest or pleasure in doing things
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Feeling down, depressed, or hopeless
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Trouble falling or staying asleep, or sleeping too much
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Feeling tired or having little energy
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Poor appetite or overeating
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Feeling bad about yourself-- or that you are a failure or have let yourself or your family down
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Trouble concentrating on things, such as reading the newspaper or watching television
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Moving or speaking so slowly that other people could have noticed? Or the opposite-- being so fidgety or restless that you have
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Thoughts that you would be better off dead or of hurting yourself in some way
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Life Course Traumas
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Abuse or chaos growing up?
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Abusive relationships?
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Physical or sexual assault?
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Wartime or war involvement?
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Other ultrastress situations
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Abusive work environments?
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Divorce or prior relationship issues/residual?
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Current relationship stress levels
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Legal Troubles
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Grief
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Family History
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General Family History
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CAD (paternal or Maternal?)
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DM (Paternal or Maternal?)
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CVA (Paternal or Maternal?)
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CKD (paternal or Maternal?)
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Cancers (Paternal or Maternal?)
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AAA (Paternal or Maternal?)
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Surgical History
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Surgical History?
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ROS/MSQ
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Head
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Headaches
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Faintness
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Dizziness
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Insomnia
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Total
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Eyes
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Watery or Itchy
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Swollen, Red, or Sticky
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Bags or dark circles
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Blurred or tunnel vision
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Total
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Ears
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Itchy Ears
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Earaches, ear infections
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Drainage from ear
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Ringing in ears, Hearing loss
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Total
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Nose
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Stuffy nose
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Sinus problems
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Hay fever
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Sneezing attacks
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Excessive mucus formation
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Total
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Mouth/Throat
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Gagging, frequent need to clear throat
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Sore throat, hoarseness, loss of voice
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Swollen or discolored tongue, gums, lips
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Chronic coughing
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Canker sores
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Total
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Skin
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Acne
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Hives, rashes, dry skin
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Hair loss
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Flushing, hot flashes
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Total
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Heart
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Chest pain
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Irregular heartbeat
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Rapid or pounding heartbeat
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Total
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Lungs
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Chest congestion
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Asthma, bronchitis
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Shortness of breath
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Difficulty breathing
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Total
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Joints/muscles
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Pain or aches in joints
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Arthritis
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Stiffness or limitation of movement
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Feeling of weakness or tiredness
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Pain or anches in muscles
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Total
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Digestive tract
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Nausea, vomiting
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Diarrhea
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Constipation
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Bloated Feeling
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Belching, passing ga
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Heartburn
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Intestinal/stomach pain
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Total
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Weight
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Binge eating/drinking
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Craving certain foods
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Excessive weight
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Underweight
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Water retention
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Compulsive Eating
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Total
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Energy
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Fatigue, sluggishness
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Apathy, lethargy
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hyperactivity
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Restlessness
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Total
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Mind
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Poor Memory
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Confusion, poor comprehension
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Difficulty in making decisions
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Stuttering or stammering
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Slurred speech
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Learning disabilities
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Poor concentration
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Poor physical coordination
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Total
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Emotions
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Mood swings
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Anger, irritability, aggressiveness
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Anxiety, fear, nervousness
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Depression
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Total
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Other
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Frequent illness
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Frequent or urgent urination
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General itch or discharge
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Total
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GRAND TOTAL
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Women only (do not add this section into grand total)
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Premenstrual symptoms
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Heavy bleeding with periods
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abnormal or irregular
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Hot flashes
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Total
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Medication History
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Allergies
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Medication List
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Supplement List
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Lifestyle History
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Nutritional and Dietary History
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Exercise History
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Stress/Mind Body History
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Sleep history
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Sitting and reading
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Watching TV
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Sitting inactive in a public place
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As a passenger in a car for an hour without abreak
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Lying down to rest in the afternoon when circumstances permit
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Sitting and talking to someone
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Sitting quietly after lunch without alcohol
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In a car while stopped for few minutes in traffic
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0-9= average score, 10-24= sleep specialist recommended
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Toxin history
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Toxin history
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Screening tests
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Cognitive tests
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Patient draw a complete clock face?
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Patient accurately name today's day of the week and location?
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Patient copy cube design?
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Patient able to follow three step command?
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Functional capacity test
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Is the patient sitting stable and balanced?
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Patient able to stand and rise with stability?
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Can the patient reach/stretch their arms over their head?
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Is the patient able to push on your hands, their palms up?
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Is the patient able to pull on your wrist, with their hands grasping?
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Can the patient grasp your hand bilaterally strong and equal?
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Can the patient stoop/pick up an item off the floor and place it?
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Can the patient lift items without losing their balance?
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Is the patient able to walk with steady gait and balance?
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When the patient picks up items off the floor, are they able to bend at knees?
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Is the patient able to kneel on the ground and rise from kneeling position?
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If the patient uses a mobility aide, are they compliant?
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Does the patient need assistance with
• • •
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Does the patient need assistance with:
• • •
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Summary and Recap
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Review Health Goals
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Order Obvious Risk Factors
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Order Labs?
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