General Medicine Clinic: Dr C Osuji

Name Today's date Date of Birth

Pictures of head and neck can be securely sent by logging into your portal or by secure text. Also, send pictures of rash that you want the doctor to evaluate

YOUR HEALTH

SYSTEMIC OR DANGEROUS SYMPTOMS

Systemic or dangerous symptoms Able to complete daily activities Fever or chills Uncontrollable shaking with chills Temperature taken with thermometer Type of thermometer used Highest temperature Thermometer nearby Type of thermometer Current temperature Initial temperature too low; 2nd try

GENERAL HISTORY

Races and ethnicities Review of systems length of cough, in weeks racing heartbeat or palpitations currently rash length of time areas affected by rash groin rash locations rash characteristics Weight gain was intentional pounds gained Weight gained over how many months Weight loss was intentional pounds lost Weight lost over how many months Bowel movement in the past day last bowel movement Still passing gas from below Usual number of BMs per day Number of days in a row with 5 + BMs Stool Bristol Scale During the past 4 WEEKS, how much bodily pain have you generally had? Joint pain due to injury Joint pain due to injury Problem joints Joints that cannot support weight or bend Duration of weak / unbendable joints Location of weak / unbendable joint duration of joint pain using joints to make them better Time required before improvement felt Time of the day drunk pain is worse typical skin height weight, in pounds Waist size, in inches Are you a smoker? history of tobacco Active tobacco smoking forms of tobacco smoked years of tobacco smoking cigarettes per day Cigars per week frequency of pipe smoking tobacco, alcohol, and drug use drinks per day During the past four weeks, how many drinks of wine, beer or other alcoholic beverages did you have? recreational drugs used history of IV drug use Currently in an intimate relationship partner IPV actions (HITS screening tool) diet

FEMALE HISTORY

Age at Menarche Has given birth Has given birth Age at first birth Pregnant or planning First pregnancy Has obstetrician or other doctor for pregnancy when planning to get pregnant Breastfeeding Periods occur regularly and once a month Frequency of periods Reasons for period irregularity Reason for lack of menstrual period First day of most recent period Years since last pap smear Has had mammogram Years since last mammogram

Medical history

Has had complete series of all standard US childhood vaccines Complete vaccination series Years since last meningococcal vaccination Has had PCV13 pneumococcal vaccine Has had PPSV23 pneumococcal vaccine Years since first PPSV23 dose History of chicken pox Allergies History of serious allergic reaction Has Epipen that is less than one year old Allergic to eggs Has immunosuppressive condition During the pas 4 WEEKS, how would you rate your health in general? Medical history Has unexpired albuterol inhaler Uses supplemental oxygen During the past 4 WEEKS, how much have you been bothered by emotional problems such as feeling anxious, depressed, irritable, sad or downhearted and blue? Psychiatric conditions Currently seeing a psychiatrist or therapist Months since most recent seizure Has neurologist for seizures History of osteoporotic fracture Uses dialysis Organ transplant details HbA1C level checked in past year Most recent HbA1C Fingerstick blood glucose levels regularly checked Typical blood glucose range Last diabetic foot exam, years ago Has diabetic retinopathy Last diabetic retinal exam, years ago Last diabetic urine protein test, years ago AIDS HIV viral load within the past year Regular HIV management clinic Cardiovascular history Types of arrhythmia Heart failure causes limitation in ordinary physical activity (NYHA class II or above) Heart valve conditions Has had cardiac stress test Most recent cardiac stress test (years ago) Cardiac stress test result Hypertension is controlled Blood pressure control methods History of cancer Type of cancer Active cancer in the past 6 months Any type of cancer treatment in the past 3 months Description of cancer treatment Blood pressure checked in past year Most recent systolic blood pressure Most recent diastolic blood pressure Cholesterol checked in past 5 years Years since last cholesterol check Has had a colonoscopy Years since last colonoscopy Has had ultrasound to look for AAA Has had DEXA Years since last DEXA Gets yearly chest CT to screen for lung cancer Time of most recent Chest CT

SURGICAL HISTORY

Surgeries

OTHER HISTORY

Other important medication information

FAMILY HISTORY

CVD history in first-degree male relatives younger than 55 or female relatives younger than 65 Other family history Male family member with breast cancer Number of family members with breast cancer History of parental hip fracture

MEDICATIONS

Regularly taking or using medications Medications taken or used Prolonged glucocorticoid use Regularly taking supplements Supplements taken How often do you have trouble taking medications the way you have been told to take them? Allergic to medications Medication allergies Prescription insurance coverage During the PAST 4 WEEKS, has your physical and emotional health limited your social activities with family friends, neighbors or groups? During the PAST 4 WEEKS, was someone available to help you if you needed and wanted help? For example, if you felt very nervous, lonely or blue, got sick and had to stay in bed, needed someone to talk to, needed help with daily chores, or needed help just taking care of yourself During the PAST 4 WEEKS, what was the hardest physical activity you could do for at least 2 minutes? Can you get places our of walking distance without help? For example, can you travel alone by bus, taxi, or drive your own car? Can you shop for groceries or clothes without help? Can you prepare your own meals? Can you do your own housework wihtout help? Can you handle your own money without help? Do you need help eating, bathing, dressing, or getting around your home? How have things been going for you during the PAST 4 WEEKS? Are you having difficulties driving your car? Do you always fasten your seat belt when you are in a car

How often during the PAST 4 WEEKS have you been BOTHERED by any of the following problems?

Fall or dizzy when standing Sexual problems Trouble eating well Teeth or dentures Problems using telephone Tired or feeling fatigue Have you fallen 2 or more times in the past year? Are you afraid of falling? Do you exercise for about 20 minutes 3 or more days a week?

Have you been given any information to help you with the following:

Hazards in your house that might hurt you? Keeping track of your medications How confident are you that you can control and manage most of your health problems?

ANYTHING ELSE

Anything elso patient would like to share