Joy McCann Culverhouse - USF Health



Joy McCann Culverhouse

Center for Swallowing Disorders

University of South Florida

COLLEGE OF MEDICINE

Phone 813-974-3374 Fax 813-974-7031

MEDICAL HISTORY FORM

NAME__________________________________________________ REFERRING DOCTOR_______________________

DATE OF BIRTH____/____/_______ AGE_____ SEX ______ PRIMARY DOCTOR_______________________

CHIEF COMPLAINT – THE MAIN REASON YOU ARE SEEING THE DOCTOR TODAY: check all that apply

____Difficulty Swallowing ____Painful Swallowing ____GERD-Heartburn-Indigestion

____Chest pain ____Weight loss ____Other _________________________________________

DESCRIPTION OF PROBLEM:

__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

PAST MEDICAL HISTORY: check all that apply

ALS

Dementia

Head injury

Muscular dystrophy

Parkinson’s disease

Myasthenia gravis

Polio

Myasthenia gravis

Huntington’s disease

Brain tumor/surgery

Stroke (CVA)

Head & neck cancer

Esophageal cancer

Thyroid Disorder

Other Cancer________________

Radiation therapy

Chemotherapy

Tracheostomy

Heart Attack

Heart Disease

High Blood Pressure

Congestive Heart Failure

Diabetes

Autoimmune Disorder

Collagen Vascular Disease

Arthritis

Lung Disease

Pneumonia or bronchitis

Asthma

Allergies (drugs, food, pollen, etc)

Sleep Apnea

Barrett esophagus

Hiatal hernia

Ulcers

HIV/AIDS

Hepatitis

Tuberculosis

Other : ________________________

SURGERIES & HOSPITALIZATIONS YEAR

___________________________________________________________________ _______________________

___________________________________________________________________ _______________________

___________________________________________________________________ _______________________

___________________________________________________________________ _______________________

PERSONAL HISTORY:

Alcohol use: Never Rarely Moderate Daily Type of alcohol________________________

Tobacco use Never Previous, quit in year_________ Current, packs/day_______How long? _________

Marital status: Single Married Widowed Divorced Separated

Occupation: ____________________________________ _Full time Part Time Retired Disabled

Patient label goes here

FAMILY HISTORY:

| |Age if |Age |Health problems or cause of death |

| |living |at death | |

|Mother | | | |

|Father | | | |

|Brother | | | |

| | | | |

|Sister | | | |

| | | | |

|Son | | | |

| | | | |

|Daughter | | | |

| | | | |

REVIEW OF SYSTEMS Check box if you are currently experiencing:

GENERAL

Fever

Chills

Weight loss

Change in appetite

Anemia

Fatigue

Weakness

Anxiety

Depression

EYES/EARS/NOSE/THROAT

Change in vision

Glasses or contacts

Change in hearing

Hearing aids

Sinus problems

Postnasal drip

Chronic runny nose

Difficulty swallowing

Painful swallowing

Lump in throat

Regurgitation

Dentures

Change in saliva

Recurrent sore throat

Hoarseness

RESPIRATORY

Heavy Snoring

C-PAP Machine

Shortness of breath

Asthma

Emphysema

Aspiration

Pneumonia

Bronchitis

Cough

Wheezing

Coughing up blood

CARDIAC

Chest pain unrelated to meals

Palpitations

Heart murmurs

Cardiac work-up w/in 1 year

High cholesterol

GASTROINTESTINAL

Blood in stool

Bowel changes

Abdominal pain

Nausea

Vomiting

Bloating

GENITOURINARY

Painful urination

Blood in urine

Discharge

Frequent urination

Urgency

Frequent bladder infections

Kidney stones

Prostate problems

ENDOCRINE

Heat or cold intolerance

Excessive thirst

Diabetes

Thyroid disease

MUSCULOSKELETAL

Joint or muscle pain

Muscle weakness in arms

Joint swelling

Osteoporosis

Osteopenia

NEUROLOGICAL

Dizziness

Fainting

Seizures

Headaches/migraines

Balance problems

Numbness/tingling in extremities

Difficulty understanding speech

Difficulty speaking

Difficulty feeding yourself

DERMATOLOGIC

Lesions

Rashes

Skin cancer

SLEEP HABITS

Difficulty falling asleep

Difficulty remaining asleep

Night-time regurgitation

Awakening due to heartburn

Not rested after sleep

Frequent waking to urinate

Joy McCann Culverhouse

Center for Swallowing Disorders

University of South Florida

COLLEGE OF MEDICINE

Phone 813-974-3374 Fax 813-974-7031

Swallowing Questionnaire

(Please complete only the sections that apply)

Name_________________________________________Age _______Date_____________________

Swallowing complaints:______________________________________________________________

____________________________________________________________________________________________________________________________________________________________________

Duration of problem:_______________________________________________________________

Onset: sudden (date:____________) gradual

Frequency: every meal every day more than once a week once a week once a month randomly

Status: getting better getting worse staying the same

Location: mouth throat esophagus combination

Strategies to make swallowing easier: __________________________________________________

__________________________________________________________________________________

Factors or foods that worsen the problem:______________________________________________

____________________________________________________________________________________________________________________________________________________________________

Change in Weight: Current weight_________ Usual weight________

Current Diet level: regular soft puree liquids only tube feeding

Nutritional Supplements: (Type and Amount)____________________________________________

Recent bronchitis or pneumonia: No Yes

Overall sense of well-being & energy level: poor fair good excellent

Associated symptoms:

Difficulty initiating a swallow

Dental problems

Can’t open mouth wide

Can’t chew hard food

Food gets stuck in mouth

Food spread all over mouth

Food falls out of mouth

Drooling

Too much saliva

Dry mouth

Changes in taste sensation

Food comes out nose

Weakness of oral muscles

Food catches high in throat

Food catches low in throat

More difficulty with solids

More difficulty with liquids

Difficulty swallowing pills

Cough/choke when swallowing

Slow eater

Worse late in day

Worse when tired

Changes in speech

Changes in voice quality

Patient label goes here

Associated symptoms (continued):

| Poor/Inadequate nutrition |

| Loss of appetite |

|Loss of enjoyment of food |

| Weight gain ( lbs) |

| Weight loss ( lbs) |

| “Lump” in your throat |

| Sore throat |

| Post nasal drip |

| Frequent throat clearing |

| Bad breath |

| Reflux |

| Throat pain when swallowing |

| Chest pain when swallowing |

| Heartburn or indigestion |

| Bitter taste in mouth |

| Worse with hot liquids |

|Worse with cold liquids |

|Food/liquids stick in chest or esophagus Regurgitation of food |

|after meals |

|Regurgitation of mucus |

|Recent bronchitis or pneumonia |

|Awaken with cough or choking |

Related Evaluations and Tests:

X-Ray Swallowing Study_____________________________________________________

Primary Care Doctor_________________________________________________________

Ear Nose and Throat_________________________________________________________

Speech Pathology___________________________________________________________

Gastroenterology____________________________________________________________

Allergy____________________________________________________________________

Neurology__________________________________________________________________

Psychiatry__________________________________________________________________

Other_____________________________________________________________________

Please send a copy of today’s visit to the following medical providers:

__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Joy McCann Culverhouse

Center for Swallowing Disorders

University of South Florida

COLLEGE OF MEDICINE

Phone 813-974-3374 Fax 813-974-7031

HOME MEDICATION LIST

ALLERGIES

Please list all allergies to medication, food, x-ray dyes, iodine, etc.

|What are you allergic to? |Reaction |

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MEDICATIONS

Please list ALL prescription and over-the-counter medication. Please include vitamins and herbal products you are currently using.

|Name of drug |Strength |# of tablets/caps |How many/when? |Reason taking |

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Patient label goes here

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