H&P Initial Visit
| | | | |
| | | | |
| | |Name | |
|Date | | |Pain Hx |ROS (circle positives) |
| | | |(onset, locations, descriptors, worse/better, treatments) |Vision/hearing |
| | | | |Lo energy |
| | | | |Sleepy |
| | | | |Dizzy/unsteady |
| | | | |Syncope |
| | | | |Falls |
| | | | |Dry mouth |
| | | | |Chest pain |
| | | | |Ulcer/GERD |
| | | | |Constipation |
| | | | |Nausea |
| | | | |Appetite |
| | | | |Weight change |
| | | | |Edema |
| | | | |Night sweats |
| | | | |Insomnia |
| | | | |Depression |
| | | | |Urine freq. |
| | | | |Confusion |
| | | | |Sex dysfxn |
|Age | | | | |
| | | | | |
|Pain Disability (3=lot) | | |
|Walking ____ | | |
|Pleasure act. ____ | | |
|Shopping ____ | | |
|Driving ____ | | |
|Exercise ____ | | |
|Bathing ____ | | |
|Toilet/cont. ____ | | |
|Thinking ____ | | |
|Sleep ____ | | |
|Appetite ____ | | |
|Mood ____ | | |
|Relationships ____ | | |
|Energy ____ | | |
|Total (0-39) ____ | | |
|PMHX (circle positives) | | |
|Headache | | |
|TMJ | | |
|Dental | | |
|Neck pain | | |
|Dysphagia | | |
|COPD | | |
|Chest pain | | |
|Cardiac problem | | |
|GI problem | | |
|GU problem | | |
|Abdominal pain | | |
|Pelvic/GU pain | | |
|Arthritis | | |
|Fibromyalgia | | |
|Joint pain | | |
|Back pain | | |
|Hip/knee pain | | |
|Muscle pain | | |
|Diabetes | | |
|Neurologic disorder | | |
|Depression | | |
|Anxiety | | |
|Sleep problems | | |
| |Pain Diary Interpretation (worst pain, med effects) |Health Habits |
| | |Tobacco |
| | |______/pk-yrs. |
| | |Street drugs? Y N |
| | |Alcohol _____/day |
| | |Ever heavy? Y N |
| | |Exercise History |
| | |Min/wk _____________ |
| | |What kind? __________ |
| |Medications |Social Support |
| | |How much help? ______ |
| | |Who helps? __________ |
| | |Hired help? Y N |
| | |Enough money? Y N |
|Family History |Positives (PMHx, ROS, others) | |
|(circle positives) | | |
|Diabetes | | |
|Arthritis | | |
|Depression | | |
|Anxiety | | |
|Neurologic disorder | | |
| | | |
| |
|Vital Signs |
|Eyes ο nl conjunctiva & lids |MS Gait ο nl Get Up and Go Test |
|Pupils ο pupils symmetrical, reactive |Extremities ο no edema |
|Fundus ο nl discs & pos elements |Check nl, circ abn ROM Strength Tone Sensory |
|Vision ο acuity and gross fields intact |Right arm ο ο ο ο |
| |Left arm ο ο ο ο |
| |Right leg ο ο ο ο |
| |Left leg ο ο ο ο |
| |Spine/back ο ο ο ο |
|ENT-External ο no scars, lesions, masses | |
|Otoscopic ο nl canals & tympanic membranes | |
|Hearing ο nl to __________________ | |
|Intranasal ο nl mucosa, septum, turbinate | |
|Ant. Oral ο nl lips, teeth, gums | |
|Oropharynx ο nl tongue, palate, pharynx | |
|Neck palp. ο symmetrical without masses |Cognition ο normal screen. Test:_________________ |
|Thyroid ο no enlargement or tenderness |Attention ο nl alertness, attentive |
|JVD ο None .v-srodiac |Cranial nerves ο w/o gross deficit |
| |Coordination ο nl rapid alternating movement |
| |DTR’s ο symmetrical, ____ (scale: 0-4+) |
| |Sensation ο nl touch, proprioception |
| |Mood ο nl screen. GDS____/15 |
|Resp. effort ο nl without retractions | |
|Chest percuss. ο no dullness or hyperresonance | |
|Chest palp. ο no fremitus | |
|Auscultation ο nl bilateral breath sounds w/o rales | |
|Heart palp. ο nl location, size |Pain Body Area: _______________________________________ |
|Cardiac ausc. ο no murmur, gallop, or rub |Inspection: |
|Carotids ο nl intensity w/o bruit | |
|Pedal pulses ο nl posterior tibial & dorsalis pedis |Palpation: |
| | |
| |Strength: |
| | |
| |Sensation: |
| | |
| |Function: |
|Breasts ο nl inspection & palpation | |
|Abdomen ο no masses or tenderness | |
|L/S ο no liver/spleen enlargement | |
|Hernia ο no hernia identified | |
|Anus/rectal ο no abnormality or masses | |
|GU male ο nl inspection & palpation |Pain Body Area: _______________________________________ |
|Prostate ο nl size w/o nodularity |Inspection: |
| | |
| |Palpation: |
| | |
| |Strength: |
| | |
| |Sensation: |
| | |
| |Function: |
|GU female ο external genitalia nl w/o lesions | |
|Int. inspection ο nl bladder, urethra, & vagina | |
|Cervix ο nl appearance w/o discharge | |
|Uterus ο nl size, position, w/o tenderness | |
|Adnexa ο no masses or tenderness | |
|Lymphatic ο nl neck & axillae | |
|Lymph other ο | |
|Additional Description of Positive Findings |
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|Assessment |
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|Plan |
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| |Educational Materials |
| |(check those given) |
| |ο Evaluation and Management of Persistent Pain |
| |ο How to Complete the Daily Pain Diary |
| |ο Using Medications for Persistent Pain |
| |ο Living Well with Persistent Pain |
| |ο Exercising with Persistent Pain |
| |ο How to Stretch |
| |ο NSAIDs |
| |ο Opioids and Persistent Pain |
| |ο Depression Medications for Persistent Pain |
| |ο Managing Constipation |
| |ο Treating Pain without Pain Pills |
| |ο Pain Care: Bill of Rights |
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