lOMoAR n n
cPSD| 244
, lOMoAR n cPSD |
n 2444
History
How can I help you today?
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Do you have any other symptoms or concerns we should discuss?
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Do you have any allergies, such as medications, food and/or latex, for
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n example? Are you taking any prescripon medications?
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Are you taking any over-the-counter or herbal medications?
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Can you tell me about any current or past medical problems you have
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n had? Any previous medical, surgical, or dental procedures?
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Do you now or have you ever smoked or chewed tobacco?
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n Have you had any contact with other sick people?
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Are you sexually active?
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Do you experience: chest pain discomfort or pressure; pain/pressure/dizziness with exert
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n on or geng angry; palpitaon; decreased exercise tolerance; blue/cold ngers or toes?
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Do you have any of the following: dizziness, fainng, spinning room, seizures, weakness,
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n numbness, ngling, tremor? n n
Do you have any of the following problems: fague, diculty sleeping, unintenonal weight
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, n loss or gain, fevers, night sweats?
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How high was your fever?
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When you urinate, have you noced: pain, burning, blood, dificulty staring or stopping,
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n dribbling, inconence, urgency during day or night or any changes in frequency?
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How severe (1-10) is the pain in your
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n chest? Do you have any pain in your
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n chest?
, RcPSD| n 24 448587
Have you noced: any bruising, bleeding gums, nose bleeds or other sites of increased
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n bleeding? Do you have any of the following: heat or cold intolerance, increased thirst,
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n increased sweaing, n
frequent urinaon, change in appete? n n n n
Do you have any problems with: nervousness, depression, lack of interest, sadness,
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n memory loss, or mood changes, or ever hear voices or see things that you know are
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n not there? n
Do you have problems with: muscle or joint pain, redness, swelling, muscle cramps,
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n joint sickness, joint swelling or redness, back pain, neck or shoulder pain,
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n hip pain? n
Are you coughing up any sputum?
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When did your cough start? n n n n
Do you have any problems with: headaches that don’t go away with aspirin or Tylenol
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n (acetaminophen), double or blurred vision, dificulty with night vision, problems hearing,
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n ear pain, sinus problems, chronic sore throats, dificulty swallowing?
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Have you ever been hospitalized? What is your name?
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Do you have pain anywhere? If so,
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n where? Physical Exams n n
Temperature
