RX Medication List
Nalini M. Dave, MD. 1201 D Briarcrest Drive, Bryan, TX 77802
Name:___________________ Age____ D.O.B________ Accompanied By_________
H / A / W / AFA
Chief Complaint:
HPI: | |
FAMILY HISTORY:
|Illness |DM |HTN |
| |Weight change | |
| |Dizzy spells | |
| |Fever or chills | |
| |Night sweats | |
| |Anxious/Depressed | |
| |Mood changes | |
| |Problems falling or remaining asleep | |
| |Suicidal thoughts | |
| |Skin rash/sores | |
| |Enlarging moles | |
| |Moles that bleed easily | |
| |Unusual headaches | |
| |Changes in your vision | |
| |Double vision | |
| |Hearing loss | |
| |Frequent ear infections | |
| |Ringing in your ears | |
| |Recurrent dizziness | |
| |Nose bleeds | |
| |Recurrent sinus infections | |
| |Abnormal tastes | |
| |Mouth/tongue sores | |
| |Hoarseness | |
| |Neck swelling | |
| |Goiter | |
| |Difficulty swallowing | |
| |Chronic cough | |
| |Wheezing | |
| |Coughing up blood | |
| |Breathlessness | |
| |Shortness of breath | |
| |Chest pain | |
| |Heart trouble | |
| |Heart murmur | |
| |High blood pressure | |
| |Swelling of legs or feet | |
| |Loss of appetite | |
| |Nausea/Vomiting | |
| |Frequent indigestion | |
| |Loss of memory | |
| |Speech difficulty | |
| |Convulsions/Seizures | |
| |Heartburn | |
| |Trouble with fatty or spicy foods | |
| |Recurrent stomach pain | |
| |Vomiting blood | |
| |Stomach ulcer | |
| |Change in bowel habits/movements | |
| |High cholesterol | |
Reason for visit? Have you seen another physician for this condition?
|Yes | |No |
| |Diarrhea | |
| |Constipation | |
| |Blood in bowel movements | |
| |Pain associated with bowel movements | |
| |Yellow jaundice | |
| |Burning with urination | |
| |Frequent urination | |
| |Urgency to urinate | |
| |Urinate in middle of night | |
| |Involuntary urine lose | |
| |Loss of urine when lifting or coughing | |
| |Accidental wet bed | |
| |Pass blood through urine | |
| |Bleed easily from cuts/abrasions | |
| |Bruise easily | |
| |History of anemia or low blood | |
| |Ever had a blood transfusion | |
| |Severe backaches | |
| |Joint pain or swelling | |
| |Leg pain/cramps | |
| |Varicose veins | |
| |Ever broken a bone | |
| |Arm/leg weakness | |
| |Los of sensation | |
| |Paralysis (anywhere) | |
| |Numbness (anywhere) | |
| |Head injury-loss of consciousness | |
| |Have you ever used birth control pills | |
| |When did you stop birth control pills | |
| |Pain with sexual relations | |
| |Any history of Herpes infection | |
| |Gonorrhea | |
| |Syphilis | |
| |Infection of the fallopian tube | |
| |Hot flashes or sweats | |
| |Any history of breast lumps/tumors | |
| |Breast discharge | |
| |Breast pain | |
| |Milk from your breast | |
| |History of blood clots in legs/phlebitis | |
| |Have any children | |
| |Have you ever used an IUD | |
| |How many miscarriages | |
| |Do you often skip periods | |
| |Ever have painful periods | |
| |Heavy periods | |
| |Ever have bleeding between periods | |
| |Age when periods began | |
| |Are you on hormones | |
| |Did you ever use diet pills | |
OPERATIONS List the year you had any of the following:
______ Appendectomy ______ Gallbladder removed ______ Hernia ______Tonsillectomy
______ Blood Transfusion ______ Heart-catheterized ____ Hysterectomy
_______ Tubal/Vasectomy ______ Accidents
______Others___________________________________________________________________
HOSPITALIZATION
Date (Start with most recent) Reason List any Major Tests or Procedures done
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
HABITS Do you use (or have you used) any of the following:
Tobacco (Never (Now (Quit (year):______; Type Used: ( Cigarettes, ( Pipe ( Cigars smokeless tobacco
Amount used per day: _______________________________ How many years_____
Alcohol (Never (Now (Quit (year):______; Type Used ( beer, ( wine, ( liquor
Amount per week: _____ 12 oz beers; _____ 6 oz wine; _____ 2 oz shots
Drug Use ( Never (Now (Quit (year):______; Type ( pot, ( cocaine, ( IV, ( pain pills,
( other______
Caffeine # Per Day: _____ Coffee (cups); _____ Tea (glasses) _____ Soda (12 oz cans)
Exercise ( None per week ( # of times / week = ______ doing what? _________________
NUTRITIONAL ASSESSMENT
Do you follow a special diet or have any dietary restrictions? ( No ( Yes
______________________________________________________________________________________
HEALTH CARE MAINTENANCE
Last Cholesterol Screen? Year_____ Value_____
Pneumonia Shot? ( Never ( Year _____; Last Tetanus shot?
Have you been involved in: ( The Military? ( International Travel?
______________________________________________________________________________________
COPING/STRESS TOLERANCE ASSESSMENT
Describe how you manage stress: (Exercise (Gardening (Hobbies (Read (Sports (TV
(Other: ______________________________________________________________________
Who lives with you? (Alone (Spouse (Children (Parent(s) (Other: _____________________
In the past year have you had a major loss or change in your life? (No (Yes
______________________________________________________________________________________
VALUABLES/BELIEFS ASSESSMENT
Do you have any of the following documents: ( Donor Card?
( Living Will?
( Durable Power of Attorney for Health Care?
Do you have any religious or cultural practices we should be aware of? (No (Yes
Describe:_____________________________________________________________________
________________________________ _______________________________
Patient/ Parent Signature / Date Completed Physician Signature / Date Reviewed
RX Medication List
Name Chart # Date
ALLERGIES
LIST YOUR CURRENT MEDICATIONS:
|NAME OF MEDICATION |DOSE |HOW FREQUENT |SIDE EFFECTS? |WHO PRESCRIBED? |
| | | | | |
| | | | | |
| | | | | |
| | | | | |
| | | | | |
| | | | | |
| | | | | |
| | | | | |
| | | | | |
| | | | | |
| | | | | |
| | | | | |
| | | | | |
Any thing else that we should know about your medications?
-----------------------
Allergies: Latex
Contrast, Food
Blood, Antibiotics,
NKDA
Chart # N Date of Exam:
Surgeries:
Tonsils Appendectomy Breast Biopsy
Hernia Knee replacement Stents
Thyroid Hip replacement Vasectomy
CABG G. Bladder
Past Medical History: (Circle positive history only)
BP Diabetes II, Cancer MI Depression, STD, HIV
BP ASCVD CHF MI AF CABG Angioplasty
Pneumonia PE TB COPD Bronchitis Asthma
Injury Head Injury Worker’s Comp injury Seizures
Hep C Blood transfusion Bleeding disorder
Rheumatoid Arthritis Sleep Apnea CVA Fracture
Patient brought in meds for review? Yes No On no meds
Current Meds: Herbs, Vitamins, OTC
Preventive Services:
Flu Vaccine Mammogram Stool for IFOB
Pneumovax Colonoscopy DT Booster
BMD Prostate Check
Social History:
Married / Single / Divorced/ Separated / Children
Smokes____ ppd for_____ Non-smoker Coffee_____
Did you ever smoke?
ETOH_____ drinks daily/monthly/yearly Non-drinker
Illicit Drugs Diet Pills
Are there any religious or cultural practices that we need to be aware of?
Education:
Occupation:
Last Job:
FOR OFFICE USE: ( Assistance required completing the form ( Non-English speaking patient
................
................
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 searches
- blood pressure medication list alphabetically
- aarp rx drug list and prices
- medication list printable
- medication list 2018 pdf
- adhd medication list for children
- personal medication list printable
- cardiac medication list pdf
- my medication list 2018
- high risk medication list ismp
- high risk medication list cms
- cardiac medication list for nurses
- free printable medication list forms