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HPI
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Social HX
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Tobacco User
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Family HX
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PCP and Date Last Seen
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Past Medical HX
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Past Medical History
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Diabetic
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High blood pressure
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High Cholesterol
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Vascular disease
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Social Determination Screening
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Patient declines social screening
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Patient accepts social screening
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In the past 2 months, did you or others you live with eat smaller meals or skip meals because you didn't have money for food?
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Are you homeless or worried that you might be in the future?
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Do you have trouble paying for your gas or electricity bills?
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Do you have trouble finding or paying for a ride (transportation)?
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Do you need daycare, or better daycare, for your kids?
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Are you without regular income?
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Do you need help finding a better job?
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Do you need help getting more education?
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Are you concerned about someone in your home using drugs or alcohol?
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Do you feel unsafe in your daily life?
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Patient screened positive and met with CSP
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Patient screened positive and did NOT met with CSP
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General [-]
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General [+]
• • •
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General Comments
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Skin [-]
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Skin [+]
• • •
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Skin Comments
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HEENT [-]
|
HEENT [+]
• • •
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|
HEENT Comments
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Neck [-]
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Neck [+]
• • •
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Neck Comments
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Breasts [-]
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Breasts [+]
• • •
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Breasts Comments
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Cardiovascular [-]
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Cardiovascular [+]
• • •
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CV Comments
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Respiratory [-]
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Respiratory [+]
• • •
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Resp Comments
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GI [-]
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GI [+]
• • •
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GI Comments
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Urinary [-]
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Urinary [+]
• • •
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Urinary Comments
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Genital (Male) [-]
|
Genital (Male) [+]
• • •
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Genital (Male) Comments
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Genital (Female) [-]
|
Genital (Female) [+]
• • •
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Genital (Female) Comments
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Periph. Vasc. [-]
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Periph. Vasc. [+]
• • •
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Periph. Vasc. Comments
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MSK [-]
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MSK [+]
• • •
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MSK Comments
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Neurologic [-]
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Neurologic [+]
• • •
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Neuro Comments
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Endocrine [-]
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Endocrine [+]
• • •
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Endo Comments
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Psychiatric [-]
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Psychiatric [+]
• • •
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Psychiatric Comments
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