Cramps Encounter Form
MENSTRUAL CRAMPS
Encounter Form
Patient Name ________________________________________________________DOB ________________________
Statement of Incident ______________________________________________________________________________
ALLERGIES ____________________Current Medications ______________________________ LMP _____________
Temp _______________ B/P _______________________________ Pulse ______________ Resp _______________
ASSESSMENT:
Yes No Does your pain/cramps begin 1-2 day before or with the onset of your period
Yes No Does your pain continue after your period
Yes No Does your pain radiate to your back/thighs
Yes No Do you have any nausea, vomiting, headache or other muscle cramping
Yes No Is your period more than 1 week late Yes No
Yes No Do you have a history of unprotected sex ___ Tobacco Use
Yes No Is there any possibility of pregnancy ___ Weight Management
Yes No Do you have a history of STD’s ___ Injury Prevention
___ Drinking/Drug use
PHYSICAL EXAMINATION: ___ School Attendance
___ School performance
Yes No Abdominal exam abnormal ___ Physical Activity
Yes No Neuro exam abnormal ___ Sexual Behavior
Yes No CV exam abnormal ___ IZ's current
Yes No ENT exam abnormal
Notes: __________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________________________________
PLAN/TREATMENT:
Yes No Menstrual sheet attached
Yes No Discuss proper diet, especially increased fluid intake
Yes No Review home remedies such as heating pad, warm bath, exercise, and relaxation techniques
Yes No Ibuprofen 600 mg
Yes No Rx Given _________________________________________________________
Discharge Instructions Given Yes No
Return to Class Yes No Adult Parent Notified (Time) __________________ RTC _________________
RN ______________________________________ MD/NP _______________________________________________
FOLLOW UP
DATE __________________________ TIME _______________
NOTES: ________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
PROVIDER ____________________________________________________________
................
................
In order to avoid copyright disputes, this page is only a partial summary.
To fulfill the demand for quickly locating and searching documents.
It is intelligent file search solution for home and business.
Related download
Related searches
- encounter for test results icd 10
- encounter for lab review icd 10
- encounter for lab icd 10
- encounter for chemotherapy icd 10
- icd 10 encounter to establish care
- facial laceration initial encounter icd 10
- encounter for documentation icd 10
- encounter screening malignant neoplasm of colon
- encounter medication management icd 10
- icd encounter preoperative clearance
- icd 10 code for encounter for ostomy
- encounter for ostomy icd 10