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Memory
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Has long has it been since the onset of memory difficulty?
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Memory impairment mostly short-term
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Forgetting where things are left is
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Repeating the same conversation is
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Asking same question over & over again is
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Difficulty recognizing family/friends is
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Difficulty handling financial affairs
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The checkbook/financial affairs is currently being handled by
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Difficulty keeping the house clean is
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Neglecting to do personal hygiene is
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Paranoid behavior is
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Accusing family & others of stealing is
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Agitation is
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Hitting is
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Being withdrawn is
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Headache
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How long have the headaches been present?
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Duration of headaches
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How many headaches in past 30 days?
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Associated with light sensitivity
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Associated with noise sensitivity
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Association with a visual disturbance
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Abortive medicines tried for headache
• • •
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Preventative medicines tried for headache
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Pain Follow Up
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Average pain level (on current pain meds)
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Highest pain level
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Lowest pain level (after taking pain meds)
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Ability to function at home w/ medications
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Side effects
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Sleep Problems
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Time go to bed on weekdays?
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Time go to bed on weekends?
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What time do you awake on weekdays?
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What time do you awake on weekends?
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How long does it take you to fall asleep?
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How many awakenings per night?
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Length of these awakenings last? (mins)
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Snore while sleeping?
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Snores most nights of the week
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Snoring is loud and disrupts family
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Cessation of breathing while sleeping
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Awakes w/ shortness of breath/gasping
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Patient awakes with headaches
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Awakes unrefreshed after 6+ hrs sleep
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Patient awakes with headaches
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Patient doses inappropriately during day
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Uncomfortable sensations in legs at night
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Has urge to move legs at night
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Walks around to relief leg discomfort
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Spouse says patient moves legs while sleeping
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Experienced weakness in the legs or other body parts while awake? (May occur in emotional situations)
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Ever had dream like images or hallucinations while waking up or falling asleep?
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Ever felt paralyzed or unable to move while waking up or falling asleep?
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Sleep talking?
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Sleep walking?
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Buprenorphine Induction
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Chief Complaint
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COWS 1
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Time medication was administered
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Scales at that time
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BP at time administered
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Heart rate at time administered
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4 mg administered by
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COWS 2
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Time medication was administered
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Scales at that time
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BP at time administered
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Heart rate at time administered
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4 mg administered by
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COWS 3
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Time medication was administered
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Scales at that time
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BP at time administered
/
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Heart rate at time administered
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4 mg administered by
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COWS 4
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Time medication was administered
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Scales at that time
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BP at time administered
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Heart rate at time administered
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4 mg administered by
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Plan section
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Seizure
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The onset is about
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The spells are described as
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Spells are associated with
• • •
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Loss of bladder control is
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Oral trauma is
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Postictal lethargy is
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The spells are occurring at a rate of about
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Family history of seizure?
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History of head injury?
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History of meningitis?
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History of encephalitis?
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Birthing complication?
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How did you deliver child?
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Premature birth?
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Developmental delay?
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Problem matriculating through school level?
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Tremor
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Which type?
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Occurs mostly when hand is at rest
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Occurs mostly with movement/action
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Disrupts when using eating utensils
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Disrupts when writing/other fine use of finger
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Tremors are attenuated with alcohol
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Family history of tremors?
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Head tremors?
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Difficultly swallowing?
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Difficulty talking?
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History of gait impairment?
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Insomnia?
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Excessive daytime sleepiness?
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