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Digitized Extract of Health Evaluation Questionnaire

CALIFORNIA INSTITUTES OF PREVENTIVE MEDICINE

05/08/02 HEALTH EVALUATION OF:

Mrs. B   Female, Age 40 MRN: 01234567890
Address     DOB: 3/12/61
City, State Zip HOME (619) 000-0000    
123 Anystreet Dr.
San Diego, CA
92130		 WORK (619) 000-0000 PCMD: Dr. Robert Johnson, MD
123 Main St.
La Mesa, CA 92041

VITAL SIGNS

Height (inches): 67 Visual Acuity: Uncorrected Retinal photo:  
Weight (lbs.): 256 Corrected With:   Reads text: Yes
Temperature: 97.4 Visual Acuity OD: 20 / 20 Pinhole OD: 20 /  
Pulse: 73 Visual Acuity OS: 20 / 20 Pinhole OS: 20 /  
#2 Pulse:   Visual Acuity Both: 20 / 20 Pinhole OS: 20 /  
Rhythm:   Audiometry:   Tonometry #1OD:  
#2 Rhythm:   CXR done:   OS:  
BP: 149/95 Clock face test performed:   Tonometry #2OD:  
#2 BP: 132/80 EKG done:   OS:  
Tine test given: Yes Hemoccult given:   Tonometry #3OD:  
Needs PPD:   Mammogram done:   OS:  
Best Vital Capacity (cc): 2925 Fasting > 2 hrs.: Yes Participant in HC study: Yes
Best FEV1 (cc): 2375 Health Assistant initials #2: JW HC study labs drawn: Yes
Health Assistant initials #1: MC Labs drawn: Yes    

DEMOGRAPHICS AND HEREDITY

  1. Ancestry: White
  2. Country of birth: United States
  3. Patient does the following type of work: Letter carrier, U.S. post office.
  4. Patient's hobbies, sports, or activities include: Crafts, football, and fishing.
  5. She is currently: divorced
  6. Patient has been married 3 or more times.
  7. Patient is currently: living with family
  8. Patient considers her main health problem to be: Weight, smoking.
  9. Education completed: high school diploma or GED.
GENERAL HEALTH
  1. Her health limits activity to some degree.
  2. Limitations are mostly due to shortness of breath or difficulty breathing.
  3. Limitations are mostly due to fatigue, tiredness, or lack of energy.
  4. Her stress level: large
  5. Doctor visits during the past 12 months: 14 times
  6. Hospitalizations over the past 12 months: 0 times
  7. Patient regularly uses seat belts.
  8. Patient believes she is more tired and has less energy compared to other people her age.
  9. She often has trouble falling asleep or staying asleep.
  10. She often awakens tired after adequate sleep.
  11. She is more sensitive than other people.
  12. She is often worried about being ill.
  13. She often feels hopeless or down in the dumps.
  14. She has difficulty saying no, or sticking up for herself.
  15. She has problems controlling her anger.
  16. She has difficulty caring for herself.
  17. Patient is having serious problems with her family.
  18. Patient is having serious problems with her job.
  19. Patient is having serious problems with her finances.
  20. Patient has used street drugs.
  21. Patient would like an HIV (AIDS) test.
NEUROLOGICAL
  1. Patient has had or has problems with dizziness.
  2. Patient has had or has some numbness in her hands or feet.
EYES
  1. Patient has had visual spots or floaters.
  2. Patient has had itchy eyes.
EARS
  1. Nothing Remarkable Noted
NOSE/SINUSES
  1. Patient has had or has frequent sneezing, watering, or nasal congestion.


MOUTH, THROAT, NECK
  1. Nothing Remarkable Noted
LUNGS
  1. Patient has had or has shortness of breath.
  2. Patient has been a cigarette smoker.
  3. Patient currently smokes.
  4. The number of cigarettes smoked: 25
  5. The number of years she has smoked is: 25
CARDIO-VASCULAR
  1. Nothing Remarkable Noted
SKIN
  1. Patient has had a mole that has changed color or size.
  2. She has acne.
  3. She has allergies to medications.
DIGESTIVE
  1. Patient has had a distinct weight gain during the last year.
  2. Patient has had indigestion or heartburn during the past year.
  3. Patient has had recurrent nausea or vomiting during the past year.
  4. She has recurrent abdominal pain.
  5. Patient has been diagnosed with esophagitis or esophageal reflux.
  6. Patient is likely to have some form of alcohol: never.
SURGERY
  1. Tubal ligation
  2. Patient has had a surgical procedure not listed.
MEDICATIONS
  1. Advil or Motrin
  2. Antacids
  3. Aspirin
  4. Tylenol
WOMEN'S HEALTH
  1. Patient does a breast exam: at least once a month
  2. Patient's last mammogram was: never.
  3. Patient is still having menstrual periods.
  4. Patient currently has irregular periods.
  5. Patient currently has a lot of pain with her periods.
  6. She has not been sexually active within the past year.
  7. She is no longer sexually active.
  8. Type of birth control used: tubal ligation
  9. Number of pregnancies: four or more
  10. Number of live births: three
  11. Patient has been physically abused as a child.
  12. Patient has been verbally abused as a child.
  13. Patient has been sexually molested as a child or adolescent.
  14. Patient has been threatened or abused as an adult by a sexual partner
  15. Her partner has threatened, pushed, or shoved her.
  16. Her partner has threatened or abused her children.
MUSCULO-SKELETAL
  1. Nothing Remarkable Noted
HOSPITALIZATIONS AND SERIOUS ILLNESS
  1. Medical and psychiatric hospitalizations not previously mentioned: 3 C-sections.
FAMILY HISTORY
  1. Alcoholism: Father and brothers
  2. Street or illegal drug use: Brothers and sisters
  3. Arthritis: Mother
  4. Serious health or emotional problem: Children
  5. Additional diseases: High blood pressure - Mother, sister, and brother.
  6. Additional diseases: Thyroid, diabetes - Mother and sister.
  7. Additional diseases: Liver failure - Grandmother.
  8. Number of siblings: five
  9. Patient is aware of the health of her biological family.
  10. Patient is in contact with all her living family of origin.
  11. One of her children has a serious health or emotional problem.
PART 1 REVIEW
  1. She currently smokes cigarettes.
  2. Patient wants an HIV blood test.
  3. The purpose is for weight management.
  4. Patient is allergic to medications.
  5. Patient is allergic to the following medications: Septra.

 
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