Term
| Alcohol/ Substance History |
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Definition
1. Proffesionalism
2, Name/ Age/ DOB- Explain Task, Consent, Confidentiality
3. Open Ended Questions & Transitions
4. Use of Alcohol, Type of, Quantity, Duration
5. C/A/G/E
6. Addiction- Relationships, Work, DUI-Neg. Consequences
7. Depression
8. Illicit Drug Use- MJ, Coc.,LSD, etc.
9. Family Hx-
10.Empathy & Offer Help
11. Present-
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Term
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Definition
- Proffesionalism
- Name-Age/DOB, Explain Task, Consent & Confidentiality
- Open Ending Questions & Transitions
- Establish Presenting Complaint & Duration
- Establishes History for presenting illness & Acquires
- Site of the Area Involved
- Motor Symptoms-Weakness, Abnormal Uncontrollable Movements, Tremors, Balance, Gait
- Sensory Symptoms- Numbness, Tingling
- Central Symptoms- Seizure, Syncope, Dizziness, Headache, Diplopia, Slurred Speech, Vision, Hearing
- Present
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Term
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Definition
- Proffesionalism
- Explain Task, Consent, Confidentiality
- Open Ended Questions and Transitions
- Sexually Active? Male/ Females?
- How Many Partners and their regularity
- Type of Sex( Vaginal, Oral, Anal)
- Protection Against STD
- Ever been diagnosed or partner been diagnosed/Treated with STD
- Symptoms of STD:Itchying, Discharge, Painful/Burning Iritation, Urgency/Frequency of Urination
- Empathy
- Present
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Term
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Definition
1. Professionalism
2. Explain Task Consent & Confidentiality
3. Open Ended Questions and Transitions
4. Age of Menarche, Normally How long does your cycle Last? Are your Cycles Normally Heavy or light?
5. LMP and how regular is your mense?
6. Dysparenua, Dysmennorrhea
7. Have you ever been pregnant? How many times?If So how many children? (Gravida PARA)
8. Urinary Incontience
9. When was your last pap smear? Results?
10. Vaginal Discharge( Color quantity, odor)
11. Present |
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Term
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Definition
- Professionalism & Consent
- Explain Procedure & Confidentiality Name Age DOB
- Open Ended Questions and Transitions
- Normal Activities of Daily Living
- Living Arrangements and Family Relations
- Appetite & Diet Changes
- Memory & Concentration
- Falls & Change in Vision & Hearing
- Urinary Incontience
- Present
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Term
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Definition
- Proffesionalism & Consent
- Explain Task & Confidentiality Name Age & DOB
- Open Ended Questions and Transitions
- Establish Presenting Complaint X Duration
- Establish Hx for Presenting Complaint
- Site of Involvement
- Pain Quality/ Severity
- Alleviating/ Exacerbating Factors
- GI Symptoms: Nausea, Vomiting, Diarrhea, Constipation, Light Colored Stool, Jaundice
- Urinary Symptoms: Dysuria, Polyuria, Hematuria, Urgency, Frequency, Tea Colored Urine
- Reproductive Symptoms: Dysmenorrhea, Amennorhea, Dyspareunia, LMP, Discharge
- Present
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