Document 4aj5X9MyBwbnQbob8dy9XJbLa

DNt*#rt6fH64fmaftn-LlRn*lftC NulMy hw J*f*e)i07nfl Patient Data Base System The ROCOM Patient Data Base System consists of two dis tinct but interrelated parts -- a Health History Questionnaire and a Physical Examination Form. Together they provide the basic information required by the physician for your comprehensive health care. The Health History Question naire is for you to answer before the physician and his staff complete the Physical Examination Form. Please follow the directions given below, then return the completed Health History Questionnaire to the physician's office. Note: Please do not remove the seals on either side of this form. PATIENT INSTRUCTIONS This health history questionnaire gives the physician informa tion he needs about your health which only you can tell him. The questionnaire is divided into sections. Please read the in structions given with each section before answering the ques tions. Please PRINT, using a bail-point pen, when you are asked to complete information. Make an (X) where you are asked to do so, pressing firmly on the pen. Spread the questionnaire out flat on a hard surface when filling it out. Do not fold or double it back on itself. Take the time you need to finish the questionnaire. Do not worry about questions you cannot answer. If you are not sure how a question should be answered, place a solid circle ( ) in the "Yes" column or in the space provided if it is not a "Yes/No" question. You will have a chance to go over these questions with the aide when you return the form to the physician's office. Copyright 1971,1974, Patient Care Systems, Inc. All rights reserved. Printed in U.S.A. COXiORXTE 0X2456 NAME OCCUPATION Height _ Weight___ Build_____ BLOOD PRESSURE Sitting R / L' (Sm. Med.Lg Obese) Standing Pulse__ R / .L / Ryyp Temp. Lying R / ,L / AGE SOC SEC # VISION Without Glasses Far R 20/ L 20/ Near R/ L/ With Glasses R 20/ L 20/ R/ L/ Tonometry R____L ___ (Ishihara plates missed) Pt # Diagnostic Tests AUDIOMETRIC TESTING 250 500 1000 2000 4000 8000 Gross Hearing PULMONARY FUNCTION Problem Number Data Base Summary/Initial Problem List Nurse's Signature Plans Results Employment status._______ -- -- - ---------- ------ - --_ Physician's signature I DATE_______________ Copyright 1971,1974, Patient Care Systems, Inc. All rights reserved. Printed in U.S.A. COLORITE 012457 IDENTIFICATION DATA * * i i n 'he following `rformaiiOr'' Dl_EA$E PP'NT Date v'Jc1'"r,`r_______ Address __ Dale of birth __ Married _____ _____ Male ^em lie .Sepa' at id Divorced Widow eo . S^'Q'e Humeyelepnonc e..s' ^ telephone art;<3 ocJe' Education .. -- years Elementary ____ years Hign ^ n;oi -- years College, Technical Business eu, Occupation ! FAMILY HISTORY: For your family members below, follow the line across ! the page and mark an X m those boxes which indicate, their present state of health ! 'good! (poor;, or their death \wnte in the causei, and any of the illnesses that they have ever had ; Print the names of your relatives | living or dead m the spaces below Father1 Mother Brothers or Sisters- Spouse. Children ------------- 1 Grandparents1 (Mark an X for illnesses Only) YOUR HEALTH HISTORY (begin here with illnesses Additional Illnesses: Mark an X in the box next to any of the following illnesses you now or ever have had. eczema u hives or rashes bronchitis diverticulosis L_! emphysema ' J eye infections hemorrhoids hernia n liver disease malaria neuralgia or neuritis pancreatitis thyroid disease chicken pox German measles scarlet fever measles mononucleosis mumps nervous exhaustion pneumonia polio kidney trouble rheumatic fever Have you ever been turned down for life insurance, military service or employment because of health problems? venereal disease yellow jaundice other . Yes___ No Major Hospitalizations: If you have ever been hospitalized for any serious medical illness or operation, write in your most recent hospitalizations below. Check this box D if you have had more than three such hospitalizations. (Do not include normal pregnancies) 1st hospitalization 2nd hospitalization Year Operation or Illness " v' yr"T; `"'-'A'1' r. T Name of Hospital ' '^"'a'1 *'* ,>u'k ; City and State 3rd hospitalization f.y r'1 1 -^i ' V,* TT Tests and Immunizations: Mark an X next to those which you have had. Enter the year when you last were given the test or 'shots," Year Year 13 19____chest x-ray 19____smallpox "shots" 13 19____kidney x-ray 19,,__tetanus "shots" :J 19____G 1 series 19____polio series 19____colon x-ray 19,___typhoid "shots" 13' 19____gallbladder x-ray 19,___ flu injections 'D! 19____electrocardiogram 19 mumps "shots" 19____TB test 19____measles "shots' 13 19____other x-rays 19 other Medicines: Mark an X in the box next to any medicines that you are now taking or that you are allergic to allergic taking to aspirin penicillin sulfa codeine antibiotics sedatives stimulants Demerol allergic taking to diet pills # antacids laxatives cold tablets ._ Signature (if filled out by other than patient)1 Copyright 1971,1974, Patient Care Systems, Inc. All rights reserved. Printed in U.S.A. CONTINUE TO NEXT PAGE COLORITE 012458 Please answer each of the following questions oy placing an (X) in the "Y,es" blank at the right if your answer to the questions is yes. or by placing an (X) in the "No" blank at the right if your an swer to the question is no If you are unable to answer for any reason, place a solid cir cle () in the "Yes'' blank. ! Are you tkpubled with stiff or painful muscles or |omts?, ............ 2 Are your joints ever swollen7.................................. ........................ 3 Are you troubled by pains in the back or shoulder7 , , .... 4 Are your feet often painful7 _ ................ 5 Are you handicapped m any way7 ... ... ............................ 6 Do you have any skin problems?. ... ........................ 7. Does your skin itch or burn? .... .............................................................. 8. Do you have trouble stopping even a small cut from bleeding?.......................... 9 Do you bruise easily7................................................................................... 10. Do you ever faint or feel faint?........................................................................ 11. Is any part of your body always numb?........................ ................................... 12. Have you ever had fits or convulsions?............................................................ 13. Has your handwriting changed lately?............................................................. 14. Do you have a tendency to shake or tremble?.................................................... 15. Are you very nervous around strangers?............................................................ 16. Do you find it hard to make decisions?............................................................ 17 Do you find it hard to concentrate or remember? ............................................ 18. Do you usually feel lonely or depressed?......................................................... 19. Do you often cry?........................................................................................... 20. Would you say you have a hopeless outlook?.................................................... 21. Do you have difficulty relaxing7...................................................................... 22. Do you have a tendency to worry a lot?........................................................... 23. Are you troubled by frightening dreams or thoughts?.......................................... 24. Do you have a tendency to be shy or sensitive?................................................ 25. Do you have a strong dislike for criticism?...................................................... 26. Do you lose your temper often?....................................................................... 27. Do little things often annoy you? .................................................................... 28. Are you disturbed by any work or family problems? .......................................... 29. Are you having any sexual difficulties? ............................................................ 30. Have you ever considered committing suicide?................................................. 31 Have you ever desired or sought psychiatric help7............................................ 32. Have you gained or lost much weight recently?.................................................. 33. Do you have a tendency to be too hot or too cold?............................................ 34. Have you lost your interest in eating lately?...................................................... 35. Do you always seem to be hungry?................................................................. 36. Are you more thirsty than usual lately?............................................................ 37. Are there any swellings in your armpits or groin? ............................................ 38. Do you seem to feel exhausted or fatigued most of the time?.............................. 39. Do you have difficulty either falling or staying asleep?...................................... 40. Do you fail to get the exercise you should?...................................................... 41. Do you smoke?............................................................................................. 42 Do you take two or more alcoholic drinks a day?.............................................. 43. Do you drink more than six cups of coffee or tea a day?.................................... 44. Have you ever used marijuana?........................................................................ 45. Have you ever used heroin, LSD or similar drugs?............................................ 46. Do you bite your nails7................................................................................. 47. Do you often ride in cars without using any safety belts?.................................. 48. list any country outside the United States you have visited in the past six months TURN TO THE NEXT PAGE I Copyright 1971, 1974, Patient Care Systems, Inc. All rights reserved. Printed in U.S.A. COLORITE 012459 s 49 Are you troubled by heartburn' 50 Do you feel bloated after eating' 51 Are you troubled by belching' 52 Do you suffer discomfort m the pit of your stomach' 53 Do you easily become nauseated (feel like vomiting)' , . 54 Have you ever vomited blood' 55 Is it difficult pr painful for you to swallow' 56 Are you constipated more than twice a month' ., 57 Are your bowel movements ever loose for more than one day' 58, Are your bowel movements ever black or bloody'...................... 59 Are your bowel movements ever grey in color' . ........ 60 Do you suffer pains when you move your bowels' ........ 61 Have you had any bleeding from your rectum? .............. 62. Do you frequently get up at night to urinate?......................... 63 Do you urinate more than five or six times a day'.................. 64 Do you wet your pants or wet your bed? ...................... 65, Have you ever had burning or pains when you urinate' ............ 66 Has your urine ever been brown, black or bloody? .................. 67. Do you have any difficulty starting your urine flow?................ 68 Do you have a constant feeling that you have to urinate? .... For Men Only 69 Is your urine stream very weak and slow' ........ 70 Has a doctor ever told you that you have prostate trouble' 71. Have you had any burning or discharge from your penis? .......... 72. Are there any swellings or lumps on your testicles? ... 73. Do your testicles get painful?................................................. For Women Only I|4. Are you having trouble with your menstrual periods? ........ 75, Have you ever had bleeding between your periods' ............... 76. Do you have heavy bleeding with your periods?....................... 77, Do you ever have bleeding after intercourse?........................... 78. Do you feel bloated and irritable before your period? . 79. Do you have hot flashes?.................................................... 80 Have you ever taken any birth control pills'.............................. 81 Have you ever had any lumps in your breasts?.......................... 82. Have you had any excessive discharges from your vagina?.......... 83. Please print the month and year of your last PAP smear .......... 84 Please print the date your last menstrual period began .......... Print the following information in the spaces at the right: 85. Number of pregnancies............................................................ 86, Number of miscarriages........................................................... 87 Number of stillbirths............................................................ 88. Number of premature births..................................................... 89. Number of children born alive.................................................. 90 Number of cesarean operations............................................ 91. Have you ever had an abortion7......... .......................... TUAN TO BACK OF THIS PAGE opyright & 1971. 1974, Patient Care Systems, Inc. All rights reserved. Printed in U S.A, COLORITE 012460 Please print your name and today s date in the appropriate spaces at the right 92. Do you have headaches more than once a week?................................... 93. Does twisting your neck quickly cause pain?...................................... 94 Have you evei had lumps or swelling in your neck? ... 95. Do you wear glasses?. .......... ............ 96. Does your eyesight ever blur? , ................ ...................... 97 Is your eyesight getting worse?.................................................................... 98. Do you ever see double?............................................................................. 99 Do you ever see colored halos around lights?............................................ 100. Do you ever have pains or itching in or around your eyes?.............................. 101. Do your eyes blink or water most of the time?.............................................. 102. Have you had any trouble with your eyes in the last two years?...................... 103. Do you have difficulty hearing?.................................................................. 104. Have you had any earaches lately? .............................................................. 105. Have you been troubled by running ears lately?............................................ 106. Do you have a repeated buzzing or other noises in your ears? ........................ 107 Do you get motion sickness riding in a car or plane?.................................... 108. Do you have any problems with your teeth?.................................................. 109. Do you have any sore swellings on your gums or jaws?.................................. 110. Is your tongue sore or sensitive?.................................................................. Ill Have your taste senses changed lately?........................................................ 112. Is your nose stuffed up when you don't have a cold?...................................... 113. Does your nose run when you don't have a cold? .......................................... 114 Do you ever have sneezing spells?................................................................ 115. Do you ever have headcolds two or more months in a row? ............ ............. 116. Does your nose ever bleed for no reason at all?............................................ 117. Is your throat ever sore when you don't have a cold?...................................... 118. Has a doctor told you that your tonsils have been enlarged?.......................... 119. Has your voice ever been hoarse when you didn't have a cold?........................ 120. Do you wheeze or have to gasp to breathe?.................................................... 121. Are you bothered by coughing spells? .......................................................... 122. Do you cough up a lot of phlegm (thick spit)?.............................................. 123. Have you ever coughed up blood?.................... ........................................... 124. Do you get chest colds more than once a month?.......................................... 125. Are you sweating more than usual or have night sweats?................................ 126. Have you ever been told that you had high blood pressure?............................ 127. Have you been bothered by a thumping or racing heart? ................................ 128. Do you ever get pains or tightness in your chest?.......................................... 129. Do you have trouble with dizziness or lightheadedness? ................................ 130. Does every little effort leave you short of breath?.......................................... 131. Do you wake up at night short of breath?...................................................... 132. Are you using more pillows to help you breathe at night?.............................. 133. Do you have trouble with swollen feet or ankles?.......................................... 134. Are you getting cramps in your legs at night or upon walking?........................ 135. Have you ever been told that you "have a heart murmur?................................ END Copyright 1971, 1974. Patient Care Systems, Inc. All rights reserved.Printed in U S.A COLORITE 012461 Name 92 Ye^_-- No __ _ 93 Yes___ No ____ 94 Yes___ _ No __ 95 Yes___ No -- 96 Yes___ - No _-- 97 Yes __ No _-- 98 Yes____ No _-- 99 Yes - No ,--. 100 Yes___ - No --_ 101 Yes __ No _-- 102 Yes___ _ No -- 103 Yes__ _ No _-- 104. Yes ____ . No -----105 Yes____ No ___ 106 Yes__ _ No ----- 107. Yes _ __ No -------- 108 Yes____ No .------109. Yes____ No _-- 110. Yes____ No _-- 111. Yes____ No --- 112. Yes____ No ------113 Yes___ . No -- 114. Yes____ No-------115. Yes------ No _-- 116, Yes___ - No __ 117 Yes____ No -------118. Yes ____ No __ 119 Yes____ No -------- 120. Yes __ No -----121, Yes __ No __ _ 122 Yes _ No -----123 Yes____ No _ 124 Yes____ No ____ 125. Yes------ No -- 126. Yes__ _ No -----127, Yes _ No -___ 128. Yes _ No ____ 129, Yes____ No _-- 130. Yes __ No -----131 Yes____ No -------132. Yes -___ No -------133. Yes____ No -----134. Yes____ No ---- 135. Yes___ _ No ____ Date 49 Yes____ No _ ___ 50 Yes .---- No -----51. Yes------ No ____ 52. Yes____ No ____ 53. Yes------ No ____ 54 Yes -- No _-- 55. Yes------ No _ ___ 56 Yes----- No __ 57. Yes------ No ____ 58 Yes------ No ____ 59. Yes------ No ____ 60. Yes------ No ____ 61, Yes------ No ____ 62. Yes -- No __ 63. Yes___ - No ____ 64. Yes------ No____ 65, Yes------ No ___ 66. Yes------ No____ 67. Yes -- No ,___ 68. Yes____ No_____ 60. Yes------ No_____ 70. Yes __ No _ 71. Yes____ No_____ 72. Yes __ No____ 73. Yes - No____ 74. Yes ------ No------- 75. Yes No .__ - 76. Yes------ No_____ 77. Yes __ No____ 78. Yes___ - No .____ 79. Yes _-- No ,,__ _ 80. Yes ------ No____ 81. Yes No____ 82. Yes------ No------- 83. 84. 85. 86. 87. 88. 89. ' 90. 91. Yes ------ No____ 1 Yes __ No____ 2, Yes------ No _-- 3 Yes -___ No -- 4 Yes------ No _-- 5 Yes____ No_____ 6. Yes------ No ------7. Yes------ No------8. Yes------ No------9. Yes----- - No ------ 10. Yes _ ___ No-------11. Yes------ No------12. Yes _ No-----13. Yes------ No --_ 14. Yes____ No------- 15. Yes------ No __ 16. Yes------ No 17. Yes____ No -- 18. Yes ____ No------19. Yes ----. No-----20. Yes -__ - No-----21. Yes------ No------22. Yes _ No-----23. Yes------ No------24. Yes____ No __ 25. Yes -- No-----26. Yes------ No------27. Yes------ No -- 28. Yes _ No-----29. Yes------ No------30, Yes------ No -- 31. Yes____ No -- 32. Yes------ No ---. 33. Yes___ - No-----34. Yes------ No------35. Yes------ No------36. Yes------ No------37. Yes------ No------38. Yes ___ No------39. Yes------ No _ 40. Yes____ No------41. Yes------ No------42. Yes ___ No ------43. Yes------ No _ 44. Yes------ No------45. Yes____ No -___ 46. Yes ~^_No-----47. Yes------ No 48. *, " ' rf*,, ` w- vyvC*TM.W 'miFJMIi,>"*7 Copyright 1971. 1974, Patient Care Systems, Inc. All rights reserved. Printed in U.S.A. COLORITE 012462 pqame __ _______ j__________ __________ ______________ _________--___________________________ Date____ _______________ Patient no. Doctor s notes------------- --------------------------------- --------------------------------------- --------------------- ---------------------------- ------------------ -- HEAD and NECK \____ frequent headaches ____ neck pains _ __ neck lumps or swelling EYES ____ wears glasses ____ blurry vision __ . eyesight worsening ____ sees double ____ sees halo __ ,, eye pains or itching ____ watering eyes eye trouble EARS ____ hearing difficulties ___ . earaches ___ _ running ears __ buzzing in ears ____ motion sickness MOWN __ dental problems ___ _ swellings on gums or |aws ____ sore tongue ____ taste changes NOSE and THROAT ____ congested nose ___ running nose ____ sneezing spells ____ headcolds ____ nose bleeds___ . sore throat ____ enlarged tonsils ___ . hoarse voice RESPIRATORY ____ wheezes or gasps _ ___ coughing spells ____ coughs up phlegm __ coughed up blood ____ chest colds ____ excessive sweating, night sweats CARDIOVASCULAR ____ high blond pressure , ___ racing heart ____ chest pains ____ dizzy spells ____ shortness of breath ____ shortness of breath at night ____ more pillows to breathe ____ swollen feet or ankles ____ leg cramps ____ heart murmur DIGESTIVE heartburn_ _ _ _ bloated stomach___ _ belching ____ stomach pains____ nausea _ __ vomited blood _ ___ difficulty swallowing____ constipation ____ loose bowels___ . black stools ____ grey stools------ pain in rectum____ . rectal bleeding__ _ URINARY night frequency____ day frequency____ wets pants or bed ____ burning on urination____ brown, black or bloody urine __-- difficulty starting urine____ urgency ____ MALE GENITAL weak urine stream____ prostate trouble------ burning or discharge ____ lumps on testicles____ painful testicles ____ FEMALE GENITAL menstrual trouble ,,___ breakthrough bleeding____ heavy bleeding ____ bleeding after intercourse____ , premenstrual tension__ _ hot flashes birth control pill____ lumps in breasts____ vaginal discharge ____ PAP smear last period PREGNANCIES gravida miscarriages stillbirths premature births * para cesareans abortion__ __ MUSCULOSKELETAL ------ aching muscles or joints ____ swollen joints ____ back or shoulder pains ____ painful feet ____ handicapped SKIN ____ skin problems ____ itching or burning skin ____ bleeds easily ___ _ bruises easily NEUROLOGICAL ____ faintness ____ numbness _ ___ convulsions ____ . change in handwriting __ trembles MOOD ____ nervous with strangers .... difficulty in making decisions ___ lack of concentration or memory --,, lonely or depressed ____ cries often ____ hopeless outlook ____ difficulty relaxing ____ worries a lot ____ frightening dreams or thoughts ____ shy or sensitive ____ dislikes criticism ____ Iqses temper ____ annoyed by little things ____ work or family problems ____ sexual difficulties ___ considered suicide ____ desired psychiatric help GENERAL . . weight Changes ___ _ tends to be hot or cold ____ loss of interest in eating ____ always hungry ____ more thirsty lately ____ armpits or groin swelling ____ fatigue ____ sleeping difficulties ____ lack of exercise ____ smokes ..... drinks alcohol daily __ heavy coffee or tea drinker .... marijuana ____ heroin, LSD. similar drugs ____ bites nails ____ doesn't use safety belts visited in last 6 months Special problems or symptoms: --------- --- --------- --- ------ _---- - --------------- ---------------- ---------- ------- ------------------------ ------------- ---------------- Signature (if filled out by other than patient):.1 ,,. ______._______ ___ ._____ Copyright 1971, 1974, Patient Care Systems, Inc. All rights reserved Printed in U.S.A. COLOR!TE 012463 Data Bas System- K(X:o.\l physical examination GENERAL a Posture b Gan c Speech d Appearance e Emotion ... _ -------_____ ____ HEAD a Hair Cl Masses C Shape d Bruits e Tenderness f. Sinus _____ ._ ____ _____ . EYES a Lids R_ l__, t Pupils R__ i____ b Sclera R__ t____ g Fundi R__ L___ c Conjunctiva R__ 1____ h Light R,,__l___ d Muscles R__ L__ - i Bruit R__ l___ _ e Cornea R__ i____ i Accommodation R____ L_____ INSTRUCTIONS: (WNL) Within Normal Limits (POS) Positive findings (X) Omitted EARS a Pinna b Canal c Drum d Weber e Rinne R____L_____ R____ I______ R____ 1______- ____ __ NOSE a, Septum b Mucosa c Obstruction MOUTH/THROAT a Lips b Breath . C Tongue _ d Pharynx . e Tonsils _ t Teeth g Dentures h Canes i Larynx j Floor k Mucosa NECK a Thyroid b Trachea c Veins d Spine e Nodes I Bruit g Carotid h Motion R__t__ fl____ L_ R____ L- LUNGS a Chest _ b Symmetry _ c Diaphragm^ d Rubs _ e Bruit f Sounds g Fremitus HEART a PMI b Rate c Rhymm d Thrill __ e Tones --------- t ______ g ___ _ Rub Murmurs ______ --------______ BREASTS a Nodes R------ 1_____ b Discharge R____L___ c Nipple R,,--l_____ d Areolar R------ 1_____ e Symmetry R____1____ _ * f Consistency R____1_____. g Scars R----- 1__ ABDOMEN a Contour ____ b Tenderness.__ c Organs __ d Masses ___ e Hernia 1 Bruit g Sounds h Femoral Pulse i log Nodes R___1____ R___ L___ R___L..... R_L__ R___1____ BACK a Curvation b Mobility c Tenderness CVA Renat Bone --------_ ______ --. FEMALE GENITALS a Labia b Bartholin gland c Urethra d Vagina e Cervix < Uterus g Adnexa h Pap smear done i Discharge MALE GENITALS a Penis b Scrotum c Testicles d Discharge e Scars 1 Meatus -- g Epididymis ___ h varicocele RECTAL a Pilonidal b Anus c Sphincter d Fissure e Prostate 1 Masses __ g Hemorrhoids _ h Sigmoid__ CM_ i Mucosa _ I Other _ SKIN a, Scars b Birthmarks , c Other marks . d, Texture e Sweat I, Color g, Ulcers NEUROLOGICAL Strength' a Biceps b, Tnceps C Knee d Ankle e Romberg f Babmsky g Cranial n h Sensory Reflex' ' Cooidmation Tremor Vibratory EXTREMITIES Color General Motion Bruns Edema Varicosities Shou Ider Arm R__ . R__ R__ R__ R__ R R__ R__ L. L___ 1___ L____ L___ I___ i Elbow 1 Radial P k Wrist I Hand m Fingers n Nails 0 Hip P Leg q Knee r Ankle s. Foot t Pedal P. u Toes v Nails When testing strength use grades Weak (W). Normal (N), Strong (S) ' When testing reflexes use Absent (A), Present (P), Brisk (B) Signature Copyright 1971,1974 Patient Care Systems, Inc All rights reserved COLOR!TE 012464 Patient name ?\ <0O> Number Date Copyright 1971,1974, Patient Care Systems, Inc. All rights reserved. Printed In U.S.A. COLORITE 012465 i pf HbrtmJrtn-L*RMn* lee Nuij Mew JmyQ7liO Created and developed by Patient Care Systems, Inc. COLORITE 012466