CT.GOV-Connecticut's Official State Website



CONNECTICUT DEPARTMENT OF DEVELOPMENTAL SERVICESHEALTH INFORMATION CHECKLISTName: FORMTEXT ?????DDS: FORMTEXT ?????DOB: FORMTEXT ?????Information Source(s): FORMCHECKBOX Individual FORMCHECKBOX Visual Assessment FORMCHECKBOX Medical Record FORMCHECKBOX Report of other (specify): FORMTEXT ?????Allergies: FORMTEXT ?????Appearance concerns: FORMCHECKBOX Check here if no problems FORMCHECKBOX Hygiene FORMCHECKBOX Grooming FORMCHECKBOX Clothing FORMCHECKBOX Other/comments: FORMTEXT ?????Skin/Scalp: FORMCHECKBOX Check here if no problems FORMCHECKBOX Wounds FORMCHECKBOX Pressure ulcer FORMCHECKBOX Rash FORMCHECKBOX Acne FORMCHECKBOX Scars FORMCHECKBOX Dryness FORMCHECKBOX Itching FORMCHECKBOX Dandruff FORMCHECKBOX Masses FORMCHECKBOX Growths FORMCHECKBOX Skin changes FORMCHECKBOX Other/comments: FORMTEXT ?????Feet: FORMCHECKBOX Check here if no problems FORMCHECKBOX Athlete’s foot FORMCHECKBOX Fungal nails FORMCHECKBOX Ingrown nails FORMCHECKBOX Overgrown nails FORMCHECKBOX Bunion FORMCHECKBOX Corn FORMCHECKBOX Callus FORMCHECKBOX Flat feet FORMCHECKBOX Swelling FORMCHECKBOX Pain FORMCHECKBOX Numbness FORMCHECKBOX Other/comments: FORMTEXT ????? Eyes: FORMCHECKBOX Check here if no problems FORMCHECKBOX Glasses FORMCHECKBOX Visual impairment FORMCHECKBOX Legally blind FORMCHECKBOX Cataracts FORMCHECKBOX Glaucoma FORMCHECKBOX Double vision FORMCHECKBOX Reddened sclera FORMCHECKBOX Itch/pain/tearing FORMCHECKBOX Macular degeneration FORMCHECKBOX Other/comments: FORMTEXT ?????Ear/Nose/Throat: FORMCHECKBOX Check here if no problems FORMCHECKBOX Hearing impairment FORMCHECKBOX Ear aches/infections FORMCHECKBOX Tinnitus FORMCHECKBOX Vertigo FORMCHECKBOX Hearing aids FORMCHECKBOX Refuses hearing aid FORMCHECKBOX Excess wax FORMCHECKBOX Nasal allergies FORMCHECKBOX Nasal congestion FORMCHECKBOX Sinus infection FORMCHECKBOX Nose bleeds FORMCHECKBOX Sore throat FORMCHECKBOX Hoarseness FORMCHECKBOX Other/comments: FORMTEXT ?????Mouth: FORMCHECKBOX Check here if no problems FORMCHECKBOX Dentures FORMCHECKBOX Mouth pain FORMCHECKBOX Mouth sores FORMCHECKBOX Tooth pain FORMCHECKBOX Missing teeth FORMCHECKBOX Gums bleeding FORMCHECKBOX Gums inflamed FORMCHECKBOX Refuses dentures FORMCHECKBOX Dental treatment regime FORMCHECKBOX Dental hygiene need FORMCHECKBOX Other/comments: FORMTEXT ?????Gastrointestinal: FORMCHECKBOX Check here if no problems FORMCHECKBOX Dysphagia FORMCHECKBOX GERD/Heartburn FORMCHECKBOX Constipation FORMCHECKBOX Loose stools FORMCHECKBOX Bowel movement changes FORMCHECKBOX Vomiting/Nausea FORMCHECKBOX Dehydration FORMCHECKBOX Rectal bleeding FORMCHECKBOX Hemorrhoids FORMCHECKBOX J, G or NG tube FORMCHECKBOX Colostomy/Ileostomy FORMCHECKBOX Dietary Restrictions: FORMTEXT ????? FORMCHECKBOX Other/comments: FORMTEXT ?????Cardiologic/vascular: FORMCHECKBOX Check here if no problems FORMCHECKBOX HTN FORMCHECKBOX Chest pain FORMCHECKBOX PRN med for chest pain FORMCHECKBOX Heart palpitations FORMCHECKBOX Heart disease FORMCHECKBOX Fainting FORMCHECKBOX Murmur FORMCHECKBOX Difficulty breathing on exertion FORMCHECKBOX Edema FORMCHECKBOX A-Fib FORMCHECKBOX Pacemaker FORMCHECKBOX Hypotension FORMCHECKBOX Orthostatic hypotension FORMCHECKBOX Varicose veins FORMCHECKBOX Other/comments: FORMTEXT ?????Musculoskeletal: FORMCHECKBOX Check here if no problems FORMCHECKBOX Back pain FORMCHECKBOX Stiffness FORMCHECKBOX Muscle weakness FORMCHECKBOX Decreased ROM FORMCHECKBOX Arthritis FORMCHECKBOX Osteoporosis FORMCHECKBOX Concerns walking FORMCHECKBOX Gait disturbance FORMCHECKBOX Osteopenia FORMCHECKBOX Scoliosis FORMCHECKBOX Loss of balance FORMCHECKBOX Spascity FORMCHECKBOX Ktare FORMCHECKBOX Joint pain FORMCHECKBOX Fractures: FORMTEXT ????? FORMCHECKBOX Other/comments: FORMTEXT ?????Respiratory: FORMCHECKBOX Check here if no problems FORMCHECKBOX Shortness of breath FORMCHECKBOX Cough FORMCHECKBOX Wheeze FORMCHECKBOX Coughing/spitting blood FORMCHECKBOX Asthma FORMCHECKBOX Aspiration FORMCHECKBOX Choking FORMCHECKBOX Congestion FORMCHECKBOX Sleep apnea FORMCHECKBOX COPD FORMCHECKBOX Oxygen use FORMCHECKBOX Suctioning FORMCHECKBOX Pneumonia FORMCHECKBOX Aspiration pneumonia FORMCHECKBOX Percussion therapy FORMCHECKBOX Postural therapy FORMCHECKBOX Cyanosis FORMCHECKBOX Bronchitis FORMCHECKBOX Tracheostomy FORMCHECKBOX Other/comments: FORMTEXT ?????Genitourinary/Renal: FORMCHECKBOX Check here if no problems FORMCHECKBOX Pain with urination FORMCHECKBOX Urgency FORMCHECKBOX Leaking urine FORMCHECKBOX Frequent urination FORMCHECKBOX Incontinent FORMCHECKBOX UTI FORMCHECKBOX Blood in urine FORMCHECKBOX Kidney disease FORMCHECKBOX Kidney stones FORMCHECKBOX Dialysis FORMCHECKBOX Catheter FORMCHECKBOX Difficulty urinating FORMCHECKBOX Other/comments: FORMTEXT ?????Constitutional: FORMCHECKBOX Check here if no problems FORMCHECKBOX Change in appetite FORMCHECKBOX Chills FORMCHECKBOX Fatigue FORMCHECKBOX Fever FORMCHECKBOX Weight loss FORMCHECKBOX Weight gain FORMCHECKBOX Insomnia FORMCHECKBOX Wake feeling unrested FORMCHECKBOX Other/comments: FORMTEXT ?????Neurological or Head: FORMCHECKBOX Check here if no problems FORMCHECKBOX Seizures FORMCHECKBOX Migraines FORMCHECKBOX Headaches FORMCHECKBOX Tingling FORMCHECKBOX Numbness FORMCHECKBOX Dizziness FORMCHECKBOX Head injury FORMCHECKBOX TBI FORMCHECKBOX TD FORMCHECKBOX Tremor FORMCHECKBOX Fainting FORMCHECKBOX Trouble w/coordination/walking FORMCHECKBOX Alzheimers FORMCHECKBOX Dementia FORMCHECKBOX Other/comments: FORMTEXT ?????Endocrine: FORMCHECKBOX Check here if no problems FORMCHECKBOX Abnormal thirst FORMCHECKBOX Hair loss FORMCHECKBOX Excess hair FORMCHECKBOX Diabetes FORMCHECKBOX Hypothyroid FORMCHECKBOX Hyperthyroid FORMCHECKBOX Other/comments: FORMTEXT ?????Hematologic/Immunologic: FORMCHECKBOX Check here if no problems FORMCHECKBOX Bruise easily FORMCHECKBOX Bleeding FORMCHECKBOX Anemia FORMCHECKBOX Blood disorder: FORMTEXT ????? FORMCHECKBOX Autoimmune disorder: FORMTEXT ????? FORMCHECKBOX Other/comments: FORMTEXT ?????Sensory: FORMCHECKBOX Check here if no problems FORMCHECKBOX Sensitive to touch FORMCHECKBOX Sensitive to noise FORMCHECKBOX Motion sickness FORMCHECKBOX Other/comments: FORMTEXT ?????Gynecologic: FORMCHECKBOX Check here if no problems FORMCHECKBOX Irregular menses FORMCHECKBOX Missed periods FORMCHECKBOX Pain w/periods FORMCHECKBOX Heavy periods FORMCHECKBOX Post-menopause FORMCHECKBOX PMS FORMCHECKBOX Hormonal therapy FORMCHECKBOX Birth control: FORMTEXT ????? FORMCHECKBOX Pelvic/genital pain FORMCHECKBOX Itching FORMCHECKBOX Vaginal Discharge FORMCHECKBOX Vaginal sores FORMCHECKBOX STD: FORMTEXT ????? FORMCHECKBOX Pain/bleeding w/intercourse FORMCHECKBOX Breast lumps FORMCHECKBOX Breast discharge FORMCHECKBOX Breast biopsies FORMCHECKBOX Self breast exam skills FORMCHECKBOX Last Mammogram: FORMTEXT ????? FORMCHECKBOX Last Pap: FORMTEXT ????? FORMCHECKBOX Pregnancies: FORMTEXT ????? FORMCHECKBOX Miscarriage: FORMTEXT ????? FORMCHECKBOX Abortion FORMCHECKBOX Hysterectomy FORMCHECKBOX Polycystic ovary disease FORMCHECKBOX Other/comments: FORMTEXT ?????Male Health: FORMCHECKBOX Check here if no problems FORMCHECKBOX Prostate exam: FORMTEXT ????? FORMCHECKBOX Testicular self-exam skills FORMCHECKBOX Genital sores FORMCHECKBOX Discharge from penis FORMCHECKBOX STD: FORMTEXT ????? FORMCHECKBOX Contraception use: FORMTEXT ????? FORMCHECKBOX Other/comments: FORMTEXT ?????Psychosocial: FORMCHECKBOX Check here if no problems FORMCHECKBOX Anxiety/Nervousness FORMCHECKBOX Depression FORMCHECKBOX Disoriented FORMCHECKBOX Frequent crying/sadness FORMCHECKBOX Increase in sleep FORMCHECKBOX Decrease in sleep FORMCHECKBOX Change in sleep pattern FORMCHECKBOX Change in usual activities FORMCHECKBOX Hallucinations FORMCHECKBOX Fearful FORMCHECKBOX Withdrawn FORMCHECKBOX Lonely FORMCHECKBOX Irritable FORMCHECKBOX Angry FORMCHECKBOX Usual stressors FORMCHECKBOX Adel SI FORMCHECKBOX Delusional FORMCHECKBOX Other/comments: FORMTEXT ?????Behavior Concerns: FORMCHECKBOX Check here if no problems FORMCHECKBOX Pica FORMCHECKBOX Self-injurious: FORMTEXT ????? FORMCHECKBOX Destructive FORMCHECKBOX Assaultive FORMCHECKBOX Running away FORMCHECKBOX Verbally abusive FORMCHECKBOX Other/comments: FORMTEXT ?????Health Habits: *Indicate type, frequency and amount FORMCHECKBOX Smoking*: FORMTEXT ????? FORMCHECKBOX Alcohol use*: FORMTEXT ????? FORMCHECKBOX Drug use*: FORMTEXT ????? FORMCHECKBOX Exercise*: FORMTEXT ????? FORMCHECKBOX Practices safe sex FORMCHECKBOX Other/comments: FORMTEXT ?????______________________________________ ___________________ Signature Date 2 ................
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