James H. Brodsky, MD, PC 4701 Willard Avenue, Suite 224 Chevy Chase, Maryland T: F:
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1 Date: Recent Health Information for: Please answer the following questions. If you are unsure, select maybe. Comments are welcomed. Completing this prior to our visit will permit more time to discuss the important issues. SKIN Yes No Maybe Comments Worrisome marks or lumps? Rash or itching? Hair or nail changes? Unusual bruising or bleeding? EYES Visual Changes in the past year? Do you have glaucoma? Do you have macular degeneration? Have you seen your eye doctor in the last 2 years? EARS/NOSE/THROAT Hearing changes in the past year? Earache or ringing in ears? Vertigo/dizziness? Troubling allergy symptoms? CARDIAC Chest pain or tightness? Palpitation or irregular heartbeat? Shortness of breath? Swelling in legs/ankles? Fainting? PULMONARY Cough, wheeze, or spitting up blood? Easily out of breath? Do you smoke? GASTROINTESTINAL Indigestion, nausea, or abdominal discomfort? Constipation or diarrhea? Rectal bleeding? GENITOURINARY (FEMALES ONLY) Urine frequency or urgency? Urine leakage (incontinence)? Pain or discharge? Sexual difficulties? Menstrual problems?
2 GENITOURINARY (MALES ONLY) Yes No Maybe Comments Pain or discharge? Sexual difficulties? Please complete separate prostate symptom scoresheet MUSCULOSKELETAL Troubling joint pain or stiffness? Troubling neck or back pain? Muscle weakness or pain? NEUROLOGIC Headaches? Numbness or tingling? Shaking or tremor? Loss of balance? PSYCHIATRIC/COGNITION Anxiety? Depression? Change in mood? Change in memory? Troubling fatigue? UPDATE CONTACT INFORMATION Best telephone to reach you: Best address: If you are employed, give name of employer and brief job description: If you work part-time or retired, what do you do that interests you? **Please list the topics you would like to discuss today:
3 Name Date THE EPWORTH SLEEPINESS SCALE (ESS) How likely are you to doze off or fall asleep in the following situations, in contrast to feeling just tired? This refers to your usual way of life in recent times. Even if you have not done some of these things recently, try to work out how they would have affected you. Use the following scale to choose the most appropriate number for each situation: 0 = would never doze 1 = slight chance of dozing 2 = moderate chance of dozing 3 = high chance of dozing SITUATION CHANCE OF DOZING (0-3) Sitting and reading Watching television Sitting inactive in a public place (e.g. theater or meeting) As a passenger in a car for an hour without a break Lying down to rest in the afternoon when circumstances permit Sitting and talking to someone Sitting quietly after a lunch without alcohol In a car, while stopped for a few minutes in the traffic TOTAL SCORE SCORE RESULTS: 1-6 Congratulations, you are getting enough sleep! 7-8 Your score is average 9 and up Very sleepy and should seek medical advice Johns, M.W. (1991). A new method for measuring daytime sleepiness: The Epworth sleepiness scale. Sleep, 14, Permission for single-use of the information contained in this material was obtained from the Associated Professional Sleep Societies, LLC, September 2006.
4 Name Date DUKE ACTIVITY STATUS INDEX Yes No Maybe Can you take care of yourself (eating, dressing, bathing, toileting)? Can you walk indoors without assistance, such as around your house? Can you walk a block or two on level ground? Can you climb a flight of stairs? Can you run a short distance, say one or two blocks? Can you do light housework, such as washing dishes or dusting? Can you do moderate housework, such as vacuuming, sweeping floors, or carrying in the groceries? Can you do heavy housework, such as scrubbing floors or moving furniture? Can you do yardwork, such as raking leaves, weeding, or pushing a power mower? Are you having sexual relations? Can you participate in moderate recreational activities, such as golf, bowling, double tennis? Can you participate in strenuous sports, such as swimming, singles tennis, skiing or basketball? Exercise Routine Please explain what you do for exercise in an average week: Sleep Routine Approximately how many hours of sleep do you get? Do you have trouble falling asleep? How many interruptions do you experience? Do you snore? Do you feel refreshed when you wake up? Alcohol Use How much and what do you drink?
5 0- NOT AT ALL 1- SOMEWHAT 2- MODERALTELY 3- ALOT BURNS DEPRESSION CHECKLIST* Instructions: Place a check in the box to the right of each of the 15 symptoms to indicate how much this type of feeling has been bothering you in the past several days. 1. Sadness: Have you been feeling sad or down in the dumps? 2. Discouragement: Does the future look bleak or hopeless? 3. Low self-esteem: Do you feel worthless or think of yourself as a loser? 4. Inferiority: Do you feel inadequate or inferior to others? 5. Guilt: Do you get self-critical and blame yourself? 6. Indecisiveness: Is it hard to make decisions? 7. Irritability and frustration: Have you been feeling angry or resentful? 8. Loss of interest in life: Have you lost interest in your career, hobbies, family or friends? 9. Loss of motivation: Do you feel overwhelmed and have to push yourself hard to do things? 10. Poor self-image: Do you think you re looking old or unattractive? 11. Appetite changes: Have you lost your appetite? Or, do you overeat compulsively? 12. Sleep changes: Is it hard to get a good night s sleep? Are you tired and sleeping too much? 13. Loss of libido: Have you lost your interest in sex? 14. Hypochondriasis: Do you worry a lot about your health? 15. Suicidal impulses: Do you think life is not worth living or think you d be better off dead?** TOTAL SCORE ON ITEMS 1 15 NAME: DATE: *Copyright 1984 by David D. Burns, M.D. (from The Feeling Good Handbook, Plume, 1990). **Anyone with suicidal urges should seek immediate help from a mental health professional.
6 Delighted Pleased Mostly Satisfied Mixed almost equally satisfied and dissatisfied Mostly dissatisfied Unhappy Terrible None 1 time 2 times 3 times 4 times 5 times or more Your Score Not at all Less than 1 time in 5 Less than half the time About half the time More than half the time Almost always Your Score MEN ONLY IPSS - International Prostate Symptom Score Name: Date: Incomplete emptying Over the past month, how often have you had a sensation of not emptying your bladder completely after you finish urinating? Frequency Over the past month, how often have you had to urinate again less than two hours after you finished urinating? Intermittency Over the past month, how often have you found you stopped and started again several times when you urinated? Urgency Over the past month, how difficult have you found it to postpone urination? Weak stream Over the past month, how often have you had a weak urinary system? Straining Over the past month, how often have you had to push or strain to begin urination? Nocturia Over the past month, how many times did you most typically get up to urinate from the time you went to bed until the time you got up in the morning? TOTAL IPSS Score Quality of life due to urinary symptoms If you were to spend the rest of your life with your urinary condition the way it is now, how would you feel about that? Total score: 0-7 Mildly symptomatic; 8-19 moderately symptomatic; severely symptomatic
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