lOM oA R . .
cP S D| 244
, lOM oA R . cP S D|
. 244 4
History
How .can .I .help .you .today?
Do .you .have .any .other .symptoms .or .concerns .we .should .discuss?
Do .you .have .any .allergies, .such .as .medications, .food .and/or .latex, .for
.example?.Are .you .taking .any .prescripon .medications?
Are .you .taking .any .over-the-counter .or .herbal .medications?
Can .you .tell .me .about .any .current .or .past .medical .problems .you .have
.had?.Any .previous .medical, .surgical, .or .dental .procedures?
Do .you .now .or .have .you .ever .smoked .or .chewed
.tobacco?.Have .you .had .any .contact .with .other .sick .people?
Are .you .sexually .active?
Do .you .experience: .chest .pain .discomfort .or .pressure; .pain/pressure/dizziness .with .exert .on
.or.geng .angry; .palpitaon; .decreased .exercise .tolerance; .blue/cold .ngers .or .toes?
Do .you .have .any .of .the .following: .dizziness, .fainng, .spinning .room, .seizures,
.weakness,.numbness, .ngling, .tremor?
Do .you .have .any .of .the .following .problems: .fague, .diculty .sleeping, .unintenonal .weight .loss
.or.gain, .fevers, .night .sweats?
How .high .was .your .fever?
When .you .urinate, .have .you .noced: .pain, .burning, .blood, .dificulty .staring .or .stopping,
.dribbling,.inconence, .urgency .during .day .or .night .or .any .changes .in .frequency?
How .severe .(1-10) .is .the .pain .in .your
.chest?.Do .you .have .any .pain .in .your
.chest?
, R cP S D| .
2 444 85 87
Have .you .noced: .any .bruising, .bleeding .gums, .nose .bleeds .or .other .sites .of .increased
.bleeding?.Do .you .have .any .of .the .following: .heat .or .cold .intolerance, .increased .thirst,
.increased .sweaing,
frequent .urinaon, .change .in .appete?
Do .you .have .any .problems .with: .nervousness, .depression, .lack .of .interest, .sadness, .memory
.loss, .or .mood .changes, .or .ever .hear .voices .or .see .things .that .you .know .are .not
.there?
Do .you .have .problems .with: .muscle .or .joint .pain, .redness, .swelling, .muscle .cramps,
.joint.sickness, .joint .swelling .or .redness, .back .pain, .neck .or .shoulder .pain, .hip
.pain?
Are .you .coughing .up .any .sputum?
When .did .your .cough .start?
Do .you .have .any .problems .with: .headaches .that .don’t .go .away .with .aspirin .or .Tylenol
.(acetaminophen), .double .or .blurred .vision, .dificulty .with .night .vision, .problems .hearing,
.ear.pain, .sinus .problems, .chronic .sore .throats, .dificulty .swallowing?
Have .you .ever .been .hospitalized? .What .is .your .name?
Do .you .have .pain .anywhere? .If .so,
.where?.Physical .Exams
Temperature