, lOMoAR cPSD| 2444
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?
, RcPSD| 24448587
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