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Patient's Information
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First Name
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Last Name
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DOB
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Gender
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DOS
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Provider
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Basic Intake
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Basic
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Weight
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Height
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Activity Level
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Systolic Blood Pressure
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Diastolic Blood Pressure
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Pulse
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Temperature
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Method of Taking Temp
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Waist
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O2 Saturation
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Hip
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Relationships
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Marital
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Childhood Trauma?
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Sexual abuse as a child?
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Physically abused as a child?
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Occupation
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Own money management
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Maintains contact with family
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Maintains contact with friends
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Light housekeeping (dishwashing, dusting, etc)
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Heavy housekeeping (laundry, vacuum, etc)
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Shopping (groceries, clothing, etc)
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Housekeeping tasks
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Year start smoking
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Year quit
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Pack per day
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Even used other tobacco products
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Number of Confidants
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How often does your partner (Mnemonic: HITS):
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Hurt
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Physically hurt you (e.g. pushed, slapped, hit, kicked, punched)?
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Insult
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Insult or talk down to you?
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Threaten
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Threaten you with harm?
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Scream
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Scream or curse at you?
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MH & Cognition
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Stress
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Stress level
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Stress PSS
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How's your stress
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How often have you felt upset of something that happened unexpectedly in last month
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How often have you felt that unable to control important things in your life last month
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How often have you felt nervous and stressed last month
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How often have you not felt confident about your ability to handle personal problems last month
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How often have you not felt things were going your way last month
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How often have you found that could not cope all the things that had to do last month
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How often have you been able to control irritations in your life last month
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How often have you not felt you were on the top of things last month
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How often have you been angered because of things that were outside of your control last month
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How often felt difficulties were piling up so high that you could not overcome them in last month
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Have you ever had a panic attack (suddenly feeling fear or panic)
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Depression
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How's your mood been recently
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Little interested 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 (for yourself or your family)
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Trouble concentrating on things, such as reading or watching television
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Moving or speaking slowly that other people could have noticed
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Or the opposite, being so fidgety or restless
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Thoughts that you would be better off dead or of hurting yourself in some day
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Sleep
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How's your sleep
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Sleep time
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How long does it take you to fall asleep
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Wake time
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Need meds to sleep
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Do you wake up in the night
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Other symptoms (headache when wakes, snoring, tired during daytime, etc)
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Medical History
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Glaucoma
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Cataracts
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Prostate cancer
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Pre-diabetic
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COPD
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Vertigo
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Vascular aneurysm
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Coronary artery diease
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PTSD
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Depression
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Diabetes
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Irritable Bowel Disease
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Restless Leg Syndrome
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Fibromyalgia
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AAA
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Low Testosterone
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Hypercholesterolemia
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Insomnia
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High blood pressure
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Hypothyroidism
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Osteoporosis
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Cancer - Breast
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Cancer - Colon
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Cancer - Lung
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Other (enter)
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Hypertension
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Pericarditis
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Heart failure
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Type 2 diabetes
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Obstructive sleep apnea
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Sleep disorder
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Heart disease
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Asthma
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Atopic dermatitis
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Insomnia or hypersomnia
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Cardiomyopathy
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COPD
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Crohns disease
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Endometriosis
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Gestational diabetes
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Gestational hypertension
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Heart failure
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Hyperthyroidism
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Inflammatory bowel disease
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Myocardial infarction
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Polycystic ovarian disease
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Syphilis
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Valve disease
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Stroke
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Atrial fibrillation
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Eclampsia
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Family History
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AAA
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Comments (family member)
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Alcohol abuse
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Comments (family member)
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Allergies
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Comments (family member)
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Arthritis
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Comments (family member)
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Bleeding Disorder
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Comments (family member)
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Cancer
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Comments (family member)
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Depression
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Comments (family member)
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Diabetes
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Comments (family member)
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Heart disease
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Comments (family member)
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Hypertension
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Comments (family member)
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Kidney disease
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Comments (family member)
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Liver disease
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Comments (family member)
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Other conditions in your family
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Comments (family member)
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Osteoporosis
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Comments (family member)
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Migraine
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Comments (family member)
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Headache
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Comments (family member)
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Lung disease COPD
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Comments (family member)
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Stroke/TIA
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Comments (family member)
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Tuberculosis
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Comments (family member)
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Mental health disorder
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Comments (family member)
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Specific Medical Questions
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Have you ever had a sexually transmitted disease (STD) in you life?
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At what age did your menstrual cycles (periods) begin
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Have you ever been pregnant
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Are you currently taking an oral contraceptive
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How long have you been taking this medication
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Have you ever been told by your doctor that you have a benign tumor in your breast
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Have you ever had a mammogram
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When was your mammogram
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On your mammogram report, whats was your breast density description
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What is your blood type
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Do you have a history of blood clots
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Do you have any pencil eraser sized nevi on your skin
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Do you or your dermatologist know the number of nevi on your skin
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Have you received any mediastinal radiation (mid chest wall and sternum)
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Do you have a history of knee injury or trauma
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Are you sexually active?
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Current or previous STI?
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Multiple Sexual partners?
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Personal history of polyps?
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Personal history of colon cancer?
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Family history of first order relative diagnosed with colon cancer before 60?
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Family history of two first order relatives diagnosed with colon cancer at any age?
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Family history of adenomatous polyps in a first order relative before age 50?
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Medication History
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Medication
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Dosage
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Units
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Frequency
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Independent with Medication Management (Can take right med, right dose at right time)
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Have you taken any diuretic medications within the past month?
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Have you taken NSAID medications within the past month on a regular basis?
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Are you currently taking a statin medication?
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Do you take aspirin on a regular basis?
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On average, how many days per week do you take aspirin? (0 - 7 days)
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Uses a pill organizer
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Can Administer Own Medications Correct Dose and Time
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Needs Assistance Taking Medications
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How many years have you been regularly taking multivitamin supplements?
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Supplement
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Dosage
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Units
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Frequency
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Allergies
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Asthma
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If Yes, treatment?
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Food (e.g. peanuts, eggs, wheat, shellfish, etc.)
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Stinging insects (e.g. bees, wasps, fire ants, etc.)
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Inhalants/breathed (e.g. pollen, pet dander, molds, etc.)
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Medications/Drugs (e.g. penicillin, sulfa, aspirin, etc.)
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Other (e.g. latex, etc.)
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Type of allergic reaction (e.g. rash, hives, ANAPHYLAXIS, itchy eyes, etc.)
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Epi Pen?
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Did any of your family members smoke at home when you were growing up?
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Have you ever had any occupational exposure to tobacco smoke?
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Have you been employed at any of the listed jobs for greater than 1 year?
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Motor Vehicle Mechanic, Wood Worker, Painter, Welder, Tool Maker or Machine Tool Operator, Miner or Quarryman,
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Insulation Worker, Meat Worker, Farmer, Dock Worker, Construction Worker, Driver, Fire Service, Cook,
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Kitchen Help, Jobs in the Chemical, Coke Manufacture, Foundry, Glass, Printing, Rubber, Steel,
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Tanning and Asbestos Compounds Industries.
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Have you ever been employed at a job involving high levels of exposure to diesel motor exhaust?
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Are you exposed to Radon in your home?
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Do you have, or have you ever had, atopic dermatitis?
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In the past year, have you had more than one episode of sneezing or nasal congestion (runny or stuffy nose), not including colds
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Do you use a tanning bed?
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Have you ever used a tanning bed?
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Approximately how many hours have you used a tanning bed?
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Do you plan to continue using tanning bed?
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Lived next to electric powerplant
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Nutrition Intake
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Nutrition Grade
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Dark-green vegetables (c-eq/wk)
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Red and orange vegetables (c-eq/wk)
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Legumes (beans and peas) (c-eq/wk)
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Starchy vegetables (c-eq/wk)
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Other vegetables (c-eq/wk)
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Fruits (per week)
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Grains - Whole grainsd (oz-eq/day)
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Grains - Refined grains (oz-eq/day)
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Protein (c-eq / week)
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Daily Servings of Nuts, Seeds, Soy
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Weekly Servings of Processed Meat
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Weekly Servings of Red Meat
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Weekly Servings of Seafood
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Weekly Servings of Saturated Fat
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Weekly Servings of White Meat
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Weekly Servings of Fish
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Dairy (Servings per Week)
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Water oz per day
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Coffee (per day)
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Soda (Servings per Day)
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Alcoholic Drinks Per Week
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Do you eat mainly organic?
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Drinks Per Week
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Beer (12 fl oz)
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Spirits (1 shot)
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Wine (5 fl oz glass)
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Other Describe
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Have you ever had a dependency on alcohol?
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Audit
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1. How often do you have a drink containing alcohol?
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2. How many drinks containing alcohol do you have on a typical day when you are drinking?
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3. How often do you have six or more drinks on one occasion?
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4. How often during the last year have you found that you were not able to stop drinking once you had started?
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5. How often during the last year have you failed to do what was normally expected from you because of drinking?
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6. How often during the last year have you been unable to remember what happened the night before because you had been drinking?
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7. How often during the last year have you needed an alcoholic drink first thing in the morning to get yourself going after a ni
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8. How often during the last year have you had a feeling of guilt or remorse after drinking?
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9. Have you or someone else been injured as a result of your drinking?
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10. Has a relative, friend, doctor, or another health professional expressed concern about your drinking or suggested you cut do
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Physical Function
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Activity Level
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Takes Care of Shopping Needs
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Takes care of Housekeeping Needs
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Bowels
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Transfer bed to chair and back
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Bladder
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Mobility
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Grooming
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Dressing
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Toilet Use
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Stairs
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Feeding
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Bathing
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Activity
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Intensity
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Minutes
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Comments
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MSQ
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Headaches
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Faintness
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Dizziness
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Insomnia
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Watery or itchy eyes
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Swollen, reddened or sticky eyelids
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Bags or dark circles under eyes
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Blurred or tunnel vision
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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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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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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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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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Excessive sweating
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Chest pain
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Chest congestion
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Irregular or skipped heartbeat
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Rapid or pounding heartbeat
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Asthma, bronchitis
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Shortness of breath
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Difficulty breathing
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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 aches in muscles
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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 gas
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Heartburn
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Compulsive eating
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Intestinal/stomach pain
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Binge eating/drinking
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Craving certain foods
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Excessive weight
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Water retention
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Underweight
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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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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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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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Frequent illness
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Frequent or urgent urination
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Genital itch or discharge
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