Preventive Physical Examination (IPPE or PPPS) Patient Questionnaire (Page 1 of 4)
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1 Preventive Physical Examination (IPPE or PPPS) Patient Questionnaire (Page 1 of 4) Date: Name Date of Birth: ILLNESSES & INJURIES AND TREATMENTS Date Description Prescription(s) Doctor CURRENT MEDICATIONS INCLUDING DIETARY SUPPLEMENTS Medication Length of use Prescribing Doctor HOSPITALIZATIONS Date Reason Hospital / City Doctor SURGICAL HISTORY (Include surgeries from childhood.) Date Operation Performed Age Hospital / City Doctor Complications SCREENING SERVICES PERFORMED IN THE LAST 10 YEARS Most Current Date Results Doctor Normal Abnormal Gynecological exam Pap Smear Mammogram Osteoporosis EKG PSA study Digital Rectal Exam-Prostate Hypertension Colon Cancer (hemoccult, flex sig, colonoscopy) Thyroid Diabetes Cholestrol Eye Exam Glaucoma Hearing Exam Depression Testing
2 Page 2 of 4 Name: Date of Birth: Date: FAMILY HISTORY Current Age Deceased Age Breast Cancer Colon Cancer Other form of Cancer Tuberculosis Diabetes Heart Disease High Blood Pressure Stroke Thyroid Disease Arthritis AAAneurysm Osteoporosis Parkinson s Disease Alzheimers Mental Illness Cause of Death Notes Father Mother Sibling M / F 1 M / F 2 M / F 3 M / F 4 M / F 5 M / F 6 Grandparents M P SOCIAL HISTORY Grade last finished Do you drink alcohol? Occupation Never Who lives with you? Rarely Once a week 2-3 times a week Daily Single Married Have you ever smoked? Long-term Relationship Number of cigarettes//years Other Do you smoke now? Number of packs daily Have you ever use drugs? Crack/Cocaine Heroin Marijuana Other ALLERGIES EXERCISE Latex Do you exercise? If yes, how often? X-ray dye Never Rarely Once a week Shellfish 2-3 times a week Daily Sensitive to cleansers or Betadine Type of exercise? Circle those that apply Medications Aerobic Walking Running If so, list medication & reaction Swimming Weights Other Medication Reaction Hearing Assessment Do you have difficulty hearing? Do you have difficulty hearing in crowds?
3 Page 3of 4 Name Date of Birth Date NUTRITIONAL ASSESSMENT YES I have an illness or condition that has made me change the kind and/or amount of food I eat. 2 I eat fewer than two meals a day. 3 I eat few fruits, vegetables or milk products 2 I have three or more drinks of beer, liquor or wine almost every day. 2 I have tooth or mouth problems that make it hard for me to eat. 2 I do not always have enough money to buy the food I need. 4 I eat alone most of the time. 1 I take three or more different prescribed or over-the-counter drugs a day. 1 Without wanting to, I have lost or gained 10 pounds in the past six months 2 I am not always physically able to shop, cook and/or feed myself. 2 The scale is scored as follows: 0 to 2 = Good nutrition. Recheck nutritional score in 6 months. 3 to 5 = Moderate nutritional risk. Improve eating habits and lifestyle. Recheck nutritional score in 3 months. 6 or more = High nutritional risk. Recommend intervention. Depression Assessment Over the past 2 weeks, have you felt down, depressed, anxious or hopeless? Over the past 2 weeks, have you felt little interest or pleasure in doing things? Have you been treated for anxiety or depression in the past? If yes, please describe below. ACTIVITIES OF DAILY LIVING QUESTIONS YES NO Can you get to places out of walking distance? Can you go shopping for necessities such as groceries, medicine or clothes? Can you prepare your own meals? Can you do your housework? Can you do your own laundry? Can you do your own handyman work? Do you take your own medicine? Do you have trouble with sleep? Can you handle your own money? Comments:
4
5 Page 4of 4 Name Date of Birth Date Please review the following information which asks about hazards found in your home. HOME SAFETY ISSUES YES NO Do you feel unsteady when you walk? When you walk through a room, do you have to walk around furniture? Do you have throw rugs on the floor? Are papers, magazines, books, shoes, boxes, blankets, towels or other objects on the floor? Do you have to walk over or around cords or wires (cords from lamps, extension cords, etc)? Are papers, shoes, books, or other objects on the stairs? Are steps broken or uneven? Is there a light over the stairway/steps? Is there a light switch available at the top and bottom of the stairs? Are handrails on stairs available and in good repair? Are handrails on outdoor steps available and in good repair? Is the carpet on the steps in good repair, not loose or torn? In the kitchen, are items stored on high shelves? Do you have a step stool that is steady and in good condition? Is your microwave above your head/shoulders? Do you have a light near the bed within easy reach? Is the path from your bed to the bathroom dark? Is there a phone in your bedroom? Is the tub or shower floor slippery? Do you need support when you get in and out of the tub or up from the toilet? Do you have working smoke detectors in your home/apartment? Do you regularly change the batteries in your smoke detectors? If you have space heaters, are they far away from flammable objects? Do you have a fire extinguisher accessible in your house? Do you have a fire exit plan? Do you have a working flashlight available for power outages? Comments: Above risk and safety issues discussed and recommendations provided as follows:
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