Children s Hospital, LHSC Cystic Fibrosis: Paediatric Clinic
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- Reynard Ryan
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1 Children s Hospital, LHSC Cystic Fibrosis: Paediatric Clinic Patient Report and Review NAME: DATE OF VISIT: Please complete the following information about details of your CF Health care since your last visit. MEDICAL CONTACTS SINCE LAST VISIT Circle yes or no to the following events that may have occurred since your last clinic visit. 1. Hospital/Emergency room visit(s) YES NO 2. Attended other clincs/doctors appointments YES NO 3. Had additional treatments/tests YES NO 4. Had consultation/referral to other health agencies YES NO If you answered yes to any of the above, please give detail below: Any problems with: Doing chest physio (percussion, PEP, etc) YES NO Taking your inhalation treatments YES NO Taking enzymes or vitamins YES NO Issues at school related to CF YES NO Other concerns or problems you wish to discuss/get more information on:
2 SYMPTOMS Circle the words that most closely describe your symptoms. CHEST Overall change since last visit: Much Much Cough: No Yes If yes, how often: What is it like: When does it occur: Only with therapy Dry Loose Day time only Night time only Day and night time If it occurs at night, does it wake you up: No Yes Sputum: No Yes Amount: Colour: Consistency: Less More Small Medium Large Clear Yellow Green Brown Thick Thin
3 Blood streaking: No Occasional Frequent Blood: No Yes If yes, how many times: Amount: Shortness of breath: No Yes If yes, how often: If yes, when: Wheezing: No Yes Triggers: Trace 1tbsp ¼ cup ½ cup Less More At rest Slight activity Moderate activity Heavy activity only At night time Unknown Exercise Other:
4 Chest Tightness: No Yes Chest Pain: No Yes Less More Description: Sharp Dull Other: Where: How Severe: How often: EARS, NOSE, MOUTH AND THROAT Nose and sinus symptoms: No Yes Nasal Discharge: Mild Moderate Severe Clear Yellow Green Nose bleeds Polyps Stuffy nose Allergies Itchy nose Post nasal drip Face/jaw pain Other:
5 Ear Symptoms: No Yes Mouth Symptoms: No Yes Soreness: Pain Hearing problems Other: Tongue Mouth Throat Other: STOMACH/DIGESTION Appetite: Good Fair Poor Weight: Increased Decreased Stomach Pain: No Yes Triggers: or more Food Not enough enzymes Other: Relievers: Where is the pain: Upper Lower Central Flank(s) Nature: Crampy Sharp Steady
6 Bowel movements: How many? per day Normal Abnormal Loose Greasy Black (tarry) Blood Other: Flatulence (gas) Nausea Rectal Prolapse Vomiting Heartburn Bloating Swelling OTHER GENERAL SYMPTOMS Sleep disturbances Headaches Skin rash Burning on urination Joint pain Menstrual Other (please specify) MEDICATIONS ENZYMES Cotazyme Powder Cotazyme ECS 8/20 Creon 10/25 Ultrase 12/25 Viokase Other Quantity: per meal per snack VITAMINS AND SUPPLEMENTS AquADEK per day ADEK tablets per day Multivitamin & Vitamin E 400IU per day Ensure/Scandishake/Resource per day Other:
7 MASK THERAPY Ventolin Dose: Morning Afternoon Evening Bedtime Hypertonic Saline % Morning Afternoon Evening Bedtime Pulmozyme Morning Afternoon Evening Bedtime TOBI 300mg Morning Evening Tobramycin Dose: 80/160mg Morning Afternoon Evening Bedtime Do you take Tobramycin: All the time Or One month one, one month off Or Treated for (#) Days Date of last course: PUFFERS Salbutamol (Ventolin) Dose: When: Beclomethasone (Qvar, Beconase) Dose: When: Flovent Dose: When: Budesonide Dose: When: Bricanyl Dose: When: Other: NASAL SPRAYS Nasonex Dose: When: Flonase Dose: When: Normal saline rinse Dose: When: Other: ANTIBIOTICS Azithromycin Dose: Cloxacillin Dose: Ciprofloxacin Dose: Keflex Dose: Septra Dose: Other: Date of last course: # of days treated
8 OTHER MEDICATIONS/ALTERNATIVE TREATMENTS PHYSIOTHERAPY Type: PEP Chest Percussion Vest Frequency: x per day
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