|
HPI
|
|
|
Gainswave Follow up
|
|
|
IV Therapy Treatment
|
|
|
Reason for Visit
|
Subjective: Chief Complaint
|
|
Patient Intake forms reviewed
• • •
|
Subjective complaints
• • •
|
|
Patient Consent Signed
• • •
|
GFE Completed
• • •
|
|
Feeling SOB
|
|
|
Type of Visit
• • •
|
|
|
Medical Weight Loss Follow Up
|
|
|
Semaglutide Instructions
|
Tirzepatide Medication Information
|
|
Hormone Follow Note
|
|
|
Hormone Follow Note
|
|
|
Follow up visit
• • •
|
Initial Date seen
|
|
Health Assessment Score
|
|
|
Pellet insertion?
|
Pellet/Injection Insertion Date
|
|
Any Adverse Effects
|
|
|
Improvement
• • •
|
|
|
Hormone Pellet Note
|
|
|
Pellet Insertion History Dates
• • •
|
|
|
Palliative Care Follow Up
|
|
|
HPI -- Details of Pain
|
|
|
Nature of Pain
• • •
|
|
|
Which of the following makes pain worse?
• • •
|
Which of the following makes pain better?
• • •
|
|
Pain Level [0-10] (Without Medication)
|
Pain Level [0-10] (With Medication)
|
|
How often does patient feel pain?
|
When does the pain occur (on a daily basis)?
• • •
|
|
Has pain affected patient's sleep?
|
How has pain interfered with patient's normal daily activities?
|
|
|
|
|
General [-]
|
General [+]
• • •
|
|
General Comments
|
|
|
Skin [-]
|
Skin [+]
• • •
|
|
Skin Comments
|
|
|
HEENT [-]
|
HEENT [+]
• • •
|
|
HEENT Comments
|
|
|
Neck [-]
|
Neck [+]
• • •
|
|
Neck Comments
|
|
|
Breasts [-]
|
Breasts [+]
• • •
|
|
Breasts Comments
|
|
|
Cardiovascular [-]
|
Cardiovascular [+]
• • •
|
|
CV Comments
|
|
|
Respiratory [-]
|
Respiratory [+]
• • •
|
|
Resp Comments
|
|
|
GI [-]
|
GI [+]
• • •
|
|
GI Comments
|
|
|
Urinary [-]
|
Urinary [+]
• • •
|
|
Urinary Comments
|
|
|
Genital (Male) [-]
|
Genital (Male) [+]
• • •
|
|
Genital (Male) Comments
|
|
|
Genital (Female) [-]
|
Genital (Female) [+]
• • •
|
|
Genital (Female) Comments
|
|
|
Periph. Vasc. [-]
|
Periph. Vasc. [+]
• • •
|
|
Periph. Vasc. Comments
|
|
|
MSK [-]
|
MSK [+]
• • •
|
|
MSK Comments
|
|
|
Neurologic [-]
|
Neurologic [+]
• • •
|
|
Neuro Comments
|
|
|
Endocrine [-]
|
Endocrine [+]
• • •
|
|
Endo Comments
|
|
|
Psychiatric [-]
|
Psychiatric [+]
• • •
|
|
Psychiatric Comments
|
|
|
Dose Requested
|
Medication 1 Refill
• • •
|
