H&P Initial Visit



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| | |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 | | |

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|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: |

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| |Strength: |

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| |Sensation: |

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| |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: |

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| |Palpation: |

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| |Strength: |

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| |Sensation: |

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| |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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