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Patient Location
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Current Clinical Concerns:
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Follow-up
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KAP or K infusion RN note
• • •
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New Concerns
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Current issues
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Severity (1-10 10 being worst)
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Duration
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Other please specify
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Palliative
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Provocative
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Symptom Control
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Review of Systems ψ
• • •
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New Symptoms
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Comment
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Exacerbation of symptoms
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Comment
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Review of Past Hx
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New Info
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Social History
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Comment
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Response to current txmt
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Tolerability issues
• • •
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Obstacles
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Side effects
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Adherent w/txmt
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Activity level
• • •
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Exercise Hours Per Week
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Exercise type
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Other please specify
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Restorative Sleep
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Sleep Rating (10 = Best, 0 = WORST)
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CPAP usage
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Sleep difficulties
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Appetite
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Nutrition
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Disordered eating
• • •
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Relationships
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Toxin Exposure
• • •
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Habits
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Habits of concern
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If yes, frequency?
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Activities decreased to use?
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Supportive Habits
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Comment
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Mood (reported)
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Mood (Denied)
• • •
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Aggression:
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Comment
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Self Injury
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Comment
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Change in physical health?
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Comment
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Constitutional
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Pain (Describe pain with Location)
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Removal of
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Location
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Neurological
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Body Concerns
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