INTAKE DATABASE FIRST NAME MIDDLE INITIAL LAST NAME HOME HEALTH AGENCY LIST YOUR MEDICAL DIAGNOSES / PAST MEDICAL HISTORY / HOSPITALIZATIONS BELOW:
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1 INTAKE DATABASE FIRST NAME MIDDLE INITIAL LAST NAME DATE OF BIRTH PRIMARY PHYSICIAN PHARMACY HOME HEALTH AGENCY LIST YOUR MEDICATIONS BELOW: LIST YOUR MEDICATIONS BELOW: LIST YOUR DRUG ALLERGIES BELOW: LIST YOUR DRUG ALLERGIES BELOW: LIST YOUR MEDICAL DIAGNOSES / PAST MEDICAL HISTORY / HOSPITALIZATIONS BELOW: LIST THE SURGERIES / INVASIVE PROCEDURES YOU HAVE HAD BELOW: What is the location of your pain? Rate your pain (on a scale of 1 10): Current Worst Best Acceptable 1.
2 How would you describe your pain? Intermittent Occasional Continuous How long have you had this pain? What is the quality of your pain? Ache Prick Cramping Sharp Dull Stabbing Throbbing What causes an increase in your pain? What relieves your pain? Medication Heat Relaxation Elevation Exercise Cold Nothing What is your current pain management plan? What parts of your life are affected by pain? Sleep Quality of life Appetite Emotions Concentration Relationship What are your goals for pain management? FAMILY AND SOCIAL HISTORY What is your marital status? What is your current living situation? Single Widow Alone SNF (skilled nursing facility) Married Widower With family Homeless Separated Significant other Nursing home Other Divorced Do you have a family member or friend that can assist in your care? Yes No What is/was your primary career? Why did you retire? Assisted living How would you describe your current activity level? How many packs of cigarettes do you smoke a day? Active Minimal How long does it take you to drink a six pack of beer, fifth of liquor, or botle of wine? A week Sedentary Restricted What was the cause of death of your Mother? What was the cause of death of your Father? Are there any other pertinent diseases that run in your family? What year did you start smoking? What year did you stop smoking? What recreational drugs do you use? (check all that apply) Unknown A month Marijuana Methamphetamines Do not drink 6 months Cocaine Heroin A day A year LSD Other 2.
3 REVIEW OF SYSTEMS Please check ( )"yes" or "no" if you have had the following symptoms: CONSTITUTIONAL Appetite change Chills Fever Insomnia (unable to sleep) Lethargy (decreased level of alertness) Malaise (fatigue/tiredness) Night sweats Acne Ulcer in old scar Previous ulcer Dryness Pruritus (itching) Lupus Rheumatoid Scleroderma Blind Macular degeneration Optic neuritis Contact lenses Dentures Hearing loss Herpes simplex (cold sores) Recent respiratory infection Spontaneous pneumothorax (lung collapse) Wear supplemental oxygen Seasonal allergies Chronic cough Pain Weakness Intended weight loss Unintended weight loss Intended weight gain Unintended weight gain INTEGUMENTARY (SKIN AND/OR BREAST) Rashes Keloids (scar overgrowth) Contact dermatitis (rash from something touching your skin) Scars ALLERGIC/IMMUNOLOGIC Steroids HIV EYES Glasses Cataracts Cataract removal EARS, NOSE, MOUTH, THROAT Ear surgery Sinus surgery Chronic sinusitis (recurrent sinusitis) Partial dentures RESPIRATORY Asthma COPD (emphysema) Respiratory infection Tuberculosis Wheezing 3.
4 Shortness of breath with exertion Angina (chest pain) Arrhythmia (abnormal heartbeat) Heart failure (CHF) Hypertension (elevated blood pressure) Hypotension (abnormally low blood pressure) Orthopnea (difficulty breathing when lying flat on your back) Varicose veins Arterial surgery Vein surgery DVT (blood clot in leg/deep leg vein) Nausea/vomiting Hiatal hernia Acid reflux Anorexia Bulimia Dysphagia (difficulty swallowing) Obesity Liver disease Foley catheter Intermittent catheter Suprapubic catheter Cystostomy Dysuria (pain with urination) Urinary frequency Painful nails Myalgias (muscle pain) Arthritis CARDIOVASCULAR (HEART) Palpitations PND (have to sit up to catch your breath when sleeping Defibrillator Pacemaker CARDIOVASCULAR (PERIPHERAL CIRCULATION) Leg swelling Claudication (leg pain with exercise) Rest pain Necrosis/gangrene GASTROINTESTINAL Jaundice Hepatitis Blood in stools Bowel incontinence Constipation Diarrhea Stomach ulcers GENITOURINARY Nocturia (waking up to urinate) Chronic renal insufficiency Kidney transplant Hemodialysis Peritoneal dialysis MUSCULOSKELETAL Previous fracture Changes in feet Alteration of gait 4.
5 Dizziness Focal headaches Weakness Muscular dystrophy Parkinson's disease Hypoglycemia (low blood sugar) Hyperglycemia (high blood sugar) Thyroid disease Bruising Lymphedema Bleeding disorder Impaired judgment Memory loss Dementia/Alzheimers Anxiety Thoracic surgery Optic neuritis Congenital spherocytosis Ear surgery Cataracts Cataract removal Spontaneous pneumothorax (lung collapse) Previous hyperbaric treatment NEUROLOGICAL Seizures Spinal cord injury Stroke Syncope (passing out) TIA (mini stroke) ENDOCRINE Addison's disease Cushing's disease HEMATOLOGIC/LYMPHATIC Hypercoaguable (clotting disorder) Family history of blood clots PSYCHIATRIC Claustophobia (fear of closed spaces) Bipolar Depression Panic attacks HYPERBARIC Seizures 2. Adriamycin Steroid use 3. Bleomycin Cancer history COPD/Emphysema Asthma Chronic sinusitis Recent high fevers Recent administration of: 1. Cisplatinum 5.
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