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Medical History
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Past Medical History
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Past Medical History Freewrite
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Past Surgical History
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Comments
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Childhood illnesses
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Comments
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Childhood Immunizations
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Comments
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Date of last PE
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PCP
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PCP Contact Information
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Specialist Physicians
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Family History
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Father's MH
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Comments
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Mother's MH
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Comments
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Sibling(s)' MH
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Comments
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Grandparent's MH
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Comments
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Children(s)' MH
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Comments
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Social History
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Marital Status
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Living arrangement comments
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Living Arrangements
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Potential Environmental Pathogen
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Does the patient feel safe at home.
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Does the patient feel safe at home . Comments
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Sexual Hx
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Comments
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if sexually active any concern for STD
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History of STD
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History of sexual Assault /violence
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History of pregnancy
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Contraceptive Method:
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Menarche started (in years ):
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Cycle description:
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Menstrual flow
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Women's Health Provider
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Occupation
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Work Comments
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Social Support
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School
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What School
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School Comments
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Caffeine
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Comments
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Alcohol
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Comments
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Other substances
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Patient's diet
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How many meals and/ or snacks do you eat in a day ?
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Do you skip any meals ?
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How many meals a week do you eat out ?
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Physical Activity
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Physical Activity.
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What do you think stops you from being active or exercising ?
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What kind of activity/ exercise do you do each week ?
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Last dental appointment
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who is your dentist
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Last eye exam every 2 -4 years for 45-54 years , every 1-3 age 55-64 . Yearly if diabetic
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Name of eye doctor
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if over 19 : when was your last Tdap ? recommendation of a booster every 10 years
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Tdap Comments
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Activities
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Hours of Computer / TV time
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Sleep comments:
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Safety
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Seatbelt Use:
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Guns in Home
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Smoke Detectors
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Carbon Monoxide Detectors
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Fire Extinguisher
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Fire Escape Plan
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Screenings :
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If over 50 years: recommendation of herpes zoster / shingles vaccine
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Shingles comment
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Flu shot this season / Note if high dose if 65 years or older
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Flu Shot comments
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Have you received two doses of varicella vaccine if you have never had chicken pox
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HPV ( age 19-26)
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HPV Comments
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Vitamin D level: history of vitamin D deficiency
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AGE 18-79 - one time test for Hep C
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Hepatitis C comments
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Breast exams
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comment box for breast exams
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Pap test (age 21 and older ) 21-29 years is every 3 years if normal
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Pap comments
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Pap test age 30-65 - every 3 years or the HPV test every 5 years
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PAP comment
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skin checks
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skin check comments
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Cholesterol : Starting Age 45 with no known risk factors
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cholesterol comments
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Diabetes Screening:
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Diabetes Screening Comments :
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Age 50-75: Colorectal Cancer Screening
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Colorectal Screening Comments:
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Lung Cancer Screening: low dose CT if any of the following over 55 and 30 pack year smoking history and current smoker or 15 yrs
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lung cancer Screening Comments:
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Osteoporosis Screening:
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Osteoporosis Screening comments:
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Thyroid Screening:
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Thyroid comments
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Baby Aspirin: adults age 50 to 59 year who have a 10 % or greater 10 year CVD risk
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Last Mammogram
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PHQ9 Depression Screen
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in the past one week:
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Little Interest or Pleasure?
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Feeling down, depressed or hopeless?
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PHQ2 Score: <3
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PHQ2 Score: 3+
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Trouble Sleeping?
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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 oneself?
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Trouble Concentrating?
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Slow, fidgety, or restless?
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Wanting to die or self harm?
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Difficulty of these problems?
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Level of severity
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PHQ9 Scoring
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Positive Depression Screen
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Negative Depression Screen
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blank field to enter info
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Mini Mental Exam
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What is the year? season ? Date ? Day? Month
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Where are we now ? State? County ? Town/City ? Hospital ? Floor ?
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repeat three objects
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I would like you to count backward from 100 by sevens.
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Earlier I told you the names of three things. Can you tell me what those were ?
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Show the patient two simple objects, such as a wristwatch and a pencil, and ask the patient to name them.
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"Repeat the phrase: No ifs, ands, or buts."
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Take the paper in your right hand , fold it in half, and put it on the floor. (The examiner gives the patient a piece of paper .
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Please read this and do what it says.
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Make up a sentence about anything: must contain a noun and verb
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Please copy this picture
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Patient's Overall Score
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Patient's Score
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Interpretation of MMSE Scores:
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scores
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