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Chief Complaints
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1.
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1st Onset Date
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Triggered by
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Worsened by
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Consult/Treatment History
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2.
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1st Onset Date
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Triggered by
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Worsened by
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Consult/Treatment History
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3.
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1st Onset Date
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Triggered by
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Worsened by
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Consult/Treatment History
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Healthcare Providers
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1. Primary Physician/Pediatrician
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Phone Number
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2. Primary Dentist/Pediatric Dentist
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Phone Number
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3. Other Specialist
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Phone Number
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Other Specialist
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Phone Number
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Other Specialist
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Phone Number
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Past Surgical/Hospitalization History - Include Date with Surgeon Name
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If you have never had any surgeries, please turn on this switch
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1.
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2.
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3.
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4.
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5.
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If you have problem with Anesthetic, please explain
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I you ever spent one night in the hospital please include reason and date's.
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Are you currently taking any blood thinners or anti-coagulants?
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If yes, please list the name(s)
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Past Medications taken related to current complaint
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1.
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2.
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3.
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Allergies
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Please turn on this switch, if you do not have any allergic reactions
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List allergies: medications, foods, and environmental triggers
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1. (Medicine)
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2. (Food)
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3. (Environmental)
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Type of allergy
• • •
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Other please specify
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Family History - Mark all appropriate diagnoses as they pertain to your relatives
• • •
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Other Family Medical Problems - Please Specify
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Social History
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Smoking/ Vaping
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Packs/Cartridges Days?
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For___ Years?
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Quit date
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Alcohol Use
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Drinks/day?
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Recreational/Illegal Drug Use
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Marijuana Use
• • •
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Do you have or have you had any of the following?
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Rhuematologic Disorder
• • •
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Autonomic Nervous System
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Cardiovascular
• • •
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Endocrinology
• • •
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Extremities
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Functional Somatic Syndrome (Behavior/ Psycho/ Social)
• • •
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Gastroenterology
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Hematology
• • •
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HEENT
• • •
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Immunology/Allergy
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Infectious Disease
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Neurologic
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Nutrition
• • •
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Oncology
• • •
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Pulmonology
• • •
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Renal
• • •
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Skin
• • •
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Pregnancy/Nursing
• • •
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If yes to any of the above, note date(s) and explain symptoms & treatment received or receiving
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BIRTH HISTORY
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Birth/Feeding History
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Maternal Age at Birth
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Birth Weight
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Gestational Age
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Weeks Gestation
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Type of Birth
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If C-Section, why?
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Birth Complications
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Pregnancy Complications
• • •
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Other please specify
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Nursing
• • •
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Please specify the duration
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AIRWAY AND SLEEP QUESTIONNAIRE - Sleep Questionnaire
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Do you have any of the following conditions?
• • •
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Please explain the conditions picked
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1st onset
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Last episodes
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Frequency and Duration
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1. Do you have any of the following conditions?
• • •
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Please explain the conditions picked
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1st onset
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Last episodes
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Frequency and Duration
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2. Do you have any of the following conditions?
• • •
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Please explain the conditions picked
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1st onset
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Last episodes
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Frequency and Duration
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FATIGUE SEVERITY SCALE AND REFLUX SYMPTOM INDEX SUPPLEMENT
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Fatigue Severity Scale (FSS) - 1 - Strongly disagree 7 -Strongly agree
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Please read the instructions here
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1. My motivation is lower when I am fatigued
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2. Exercise brings on my fatigue
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3. I am easily fatigued
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4. Fatigue interferes with my physical functioning
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5. Fatigue causes frequent problems for me
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6. My fatigue prevents sustained physical functioning
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7. Fatigue interferes with carrying out certain duties and responsibilities
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8. Fatigue is among my most disabling symptoms
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9. Fatigue interferes with my work, family, or social life
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Visual Analogue Fatigue Scale (VAFS)
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Pick the number which describes your global fatigue with 1 being lowest and 10 being best
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Reflux Symptom Index - 0-No Problem 10-Severe Problem
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1. Hoarseness or a problem with your voice
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2. Clearing your throat
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3. Excess throat mucous or postnasal drip
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4. Difficulty swallowing food, liquids or pills
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5. Coughing after you eat or after lying down
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6. Breathing difficulties or choking episodes
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7. Troublesome or annoying cough
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8. Sensations of something sticking or a lump in throat
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9. Heartburn, chest pain, indigestion, or stomach acid coming up
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Total
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Symptom of LRP (Laryngopharyngeal Reflux/Heart Burn)
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Intermittent dysphonia (difficulty producing speech)
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Sialorrhea (hypersalivation)
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Cervical dysphagia (difficulty swallowing)
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Dysgeusia (distorted sense of taste)
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Halitosis (bad breath)
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Throat pain
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PAIN QUESTIONNAIRE SUPPLEMENT
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Please read the instructions here
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Facial Pain, Head Pain, Headaches
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Face (location)
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New Single Select
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1st onset
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R / L
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Severity
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Frequency
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Duration
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Forehead (frontal)
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1st onset
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R / L
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Severity
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Frequency
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Duration
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Temples (temporal)
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1st onset
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R / L
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Severity
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Frequency
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Duration
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Back of the head
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1st onset
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R / L
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Severity
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Frequency
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Duration
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Top of the head
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1st onset
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R / L
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Severity
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Frequency
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Duration
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Morning headaches-location
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New Single Select
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1st onset
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R / L
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Severity
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Frequency
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Duration
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“Migraine” headaches
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1st onset
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R / L
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Severity
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Frequency
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Duration
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“Cluster” headaches
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1st onset
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R / L
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Severity
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Frequency
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Duration
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When experiencing pain, do you experience
• • •
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Burning sensation - Location(s)
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Eye Orbital & Ear Problems
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Eye (orbital) pain: above, below, behind
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1st onset
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R / L
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Severity
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Frequency
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Duration
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Light sensitivity (photophobia)
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1st onset
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R / L
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Severity
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Frequency
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Duration
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Watering of the eyes
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1st onset
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R / L
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Severity
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Frequency
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Duration
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Bloodshot eyes (hyperemia)
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1st onset
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R / L
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Severity
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Frequency
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Duration
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Blurring of vision
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1st onset
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R / L
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Severity
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Frequency
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Duration
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Bulging appearance
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1st onset
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R / L
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Severity
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Frequency
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Duration
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Pressure behind the eyes
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1st onset
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R / L
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Severity
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Frequency
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Duration
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Hissing, buzzing or ringing (tinnitus)
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1st onset
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R / L
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Severity
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Frequency
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Duration
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Diminished hearing (subjective hearing loss)
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1st onset
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R / L
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Severity
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Frequency
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Duration
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Ear pain without infection (otalgia)
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1st onset
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R / L
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Severity
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Frequency
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Duration
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Clogged, stuffy, “itchy ears (feeling of fullness)
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1st onset
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R / L
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Severity
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Frequency
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Duration
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Balance problems, “vertigo” (disequilibrium)
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1st onset
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R / L
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Severity
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Frequency
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Duration
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Jaw Joint (TMJ) Problems
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Joint clicking/popping
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1st onset
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R / L
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Severity
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Frequency
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Duration
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Joint grating sounds (crepitus)
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1st onset
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R / L
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Severity
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Frequency
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Duration
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Jaw locking opened
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1st onset
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R / L
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Severity
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Frequency
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Duration
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Jaw locking closed
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1st onset
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R / L
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Severity
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Frequency
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Duration
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Pain in jaw when opening wide
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1st onset
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R / L
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Severity
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Frequency
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Duration
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Pain in jaw when chewing
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1st onset
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R / L
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Severity
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Frequency
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Duration
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Pain in jaw at rest
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1st onset
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R / L
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Severity
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Frequency
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Duration
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Pain in joint when opening wide
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1st onset
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R / L
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Severity
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Frequency
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Duration
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Pain in joint when chewing
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1st onset
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R / L
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Severity
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Frequency
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Duration
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Pain in joint at rest
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1st onset
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R / L
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Severity
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Frequency
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Duration
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Jaw deviates/deflect on opening
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1st onset
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R / L
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Severity
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Frequency
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Duration
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Uncontrollable jaw, tongue movements
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1st onset
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R / L
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Severity
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Frequency
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Duration
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Limited opening
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1st onset
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R / L
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Severity
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Frequency
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Duration
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Neck & Extremity Problems
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Lack of mobility-reduced range of movement
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1st onset
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R / L
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Severity
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Frequency
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Duration
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Neck aches/pain
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1st onset
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R / L
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Severity
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Frequency
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Duration
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Shoulder aches/pain
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1st onset
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R / L
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Severity
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Frequency
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Duration
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Upper back aches/pain
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1st onset
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R / L
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Severity
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Frequency
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Duration
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Lower back aches/pain
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1st onset
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R / L
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Severity
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Frequency
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Duration
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Arm and finger tingling, numbness or pain (circle correct description)
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1st onset
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R / L
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Severity
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Frequency
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Duration
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Legs or feet tingling, numbness or pain (circle correct description)
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1st onset
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R / L
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Severity
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Frequency
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Duration
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ACCIDENT HISTORY SUPPLEMENT
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History of Accident /or Injury
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A motor vehicle accident - Date
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A motorcycle accident - Date
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A work-related incident - Date
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A playground incident - Date
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An athletic endeavor - Date
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A fight - Date
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A fall - Date
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An accident - Date
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Hit by an object - Date
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Hit an object - Date
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Whiplash - Date
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Injury to Head
• • •
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Other please specify
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Injury of TMJ, Jaw or Mouth
• • •
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Other please specify
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Injury to Upper Body
• • •
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Other please specify
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Injury to Lower Body
• • •
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Other please specify
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***If in a vehicle
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Where was the vehicle hit?
• • •
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Other area
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Forcibly struck the
• • •
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Other please specify
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I was the driver
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I was the passenger
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