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? |

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Any thing else that we should know about your medications?

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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

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