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Medical History
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Family History
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Social History
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Review of Sytems
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Review of Systems
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All Fields Must Be Answered
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Allergic/Immunologic
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Food allergy
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Hives
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Runny nose
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Pollen/Seasonal allergy
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Environmental allergy
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Sneezing
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Cardiovascular
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Chest Pain
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Palpitations (irregular heart beat)
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Fainting
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Heart murmur
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Constitutional
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Recent weight gain
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Unexpected loss
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Recent fever
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Recent fatigue
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Recent chills
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Generalized weakness
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Endocrine
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Intolerance to cold
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Intolerance to heat
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Excessive urination
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Excessive thirst
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Ear, Nose & Throat
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Nose bleeds
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Ear pain
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Tinnitus (ringing in the ears)
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Hoarseness
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Difficulty swallowing
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Headache
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Eyes
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Eye Pain
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Eye redness
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Corrective lenses
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Double vision
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Blurred vision
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Watery eyes
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Gastrointestinal
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Urgent bowel movements
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Heartburn
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Nausea
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Vomiting
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Constipation
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Melena (bloody/tarry stools)
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Hematemesis (vomiting blood)
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Diarrhea
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Genitourinary
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Urgent urination
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Urinary retention (unable to urinate)
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Difficult urination
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Incontinence (inability to hold urine)
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Hematuria (blood in urine)
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Dysuria (painful urination)
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Flank pain
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Hematologic/Lymphatic
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Lymphadenopathy (enlarged lymph nodes)
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Easy bleeding
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Easy brusing
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Integumentary
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Rash
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itching
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Skin redness
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Poor healing wounds
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Nail changes
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New or changing skin moles
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Skin changes
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Skin color change
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Musculoskeletal
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Joint Pain
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Joint Swelling
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Joint Stiffness
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Joint Warmth
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Joint Redness
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Muscle Weakness
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Muscle Pain
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Muscle Stiffness
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Mid-back (Thoracic) pain
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Low back pain
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Neck pain
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Neurological
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Numbness
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Tingling
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Tremors
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History of seizures
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Dizziness
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Unsteady gait
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Respiratory
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Wheezing
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Painful breathing
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Cough
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Chest tightness while breathing
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Shortness of breath
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Snoring
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Psychiatric
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Memory loss
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Insomnia (inability to sleep )
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Excessive Stress
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Hallucinations
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Depression
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Anxiety
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Nervousness
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COVID-19
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Have you traveled in an airplane in the last two weeks?
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Have you been exposed to a person that has traveled by airplane in the last two weeks?
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Exposed to a person with fever, cough, sore throat in the last 2 weeks?
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Have you gathered with any people outside your household indoors?
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Have you gathered with more than 5 people outdoors?
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Have you had a recent loss of smell or taste?
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Have you had a fever in the last two weeks?
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Alerts
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Do you have a Pacemaker?
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Do you have a Defibrillator?
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Do you take blood thinners?
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Are you allergic to Adhesive?
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Are you allergic to Iodine?
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Are you allergic to Latex?
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Are you allergic to contrast dye?
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PHQ-9 Scoreable
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Over the last 2 weeks, how often have you been bothered by any of the following problems? Please select the appropriate answer?
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1. Little interest or pleasure in doing things
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2. Feeling down, depressed or hopeless
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3. Trouble falling or staying asleep, or sleeping too much
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4. Feeling tired or having little energy
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5. Poor appetite or over eating
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6. Feeling bad about yourself — that you are a failure or have let yourself or your family down
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7. Trouble concentrating on things, such as reading the newspaper or watching television
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8. Moving or speaking so slowly that other people could have noticed. Or the opposite - being so fidgety or restless that you hav
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9. Thoughts that you would be better off dead, or of hurting yourself
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TOTAL
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10. If you checked off any problems, how difficult have these problems made it for you to do your work, take care of things at h
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Lumbar Disability Mod Med Scored
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I have had back pain for
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Section 1: Pain Intensity
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Section 2: Personal Care
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Section 3: Lifting
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Section 4: Walking
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Section 5: Sitting
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Section 6: Standing
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Section 7: Sleeping
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Section 8: Social Life
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Section 9: Traveling
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Section 10: Changing Degree of Pain
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Score
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NECK PAIN DISABILITY QUESTIONNAIRE
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I have had neck pain for
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SECTION 1 - Pain Intensity
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SECTION 2 - Personal Care (Washing, Dressing, etc…)
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SECTION 3 - Lifting
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SECTION 4 - Reading
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SECTION 5 - Headaches
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SECTION 6 - Concentration
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SECTION 7 - Work
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SECTION 8 - Driving
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SECTION 9 - Sleeping
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SECTION 10 - Recreation
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