Health Promotion: Wears glasses or contacts last vision check or glaucoma test and how coping with loss of vision if any.Įars: Earaches, infections, discharge and its characteristics, tinnitus or vertigo. Head: Any unusual frequent or severe headache, any head injury, dizziness (syncope) or vertigo.Įyes: Difficulty with vision (decreased acuity, blurring, blind spots), eye pain, diplopia (double vision), redness or swelling, watering or discharge, glaucoma or cataracts. Health Promotion: Method of self-care for hair and nails. Nails: change in shape, color, or brittleness. Patient states that they shower once/day and applies lotion after bathing. Patient states that they apply sunscreen at the beginning of the day but will occasionally not take time to re-apply sunscreen later in the day.
Patient states that they get an average of 8-10 hours in the sun during the Summer, during life-guarding season. Health Promotion: Amount of sun exposure method of self-care for skin.
T: Has not used any medications on this site. R: Nothing appears to relieve this condition. Patient has noticed a recent change in a mole, but denies all other diseases listed:ĭ: It has been consistently growing larger, with occasional bleeding.Ĭ: Experiences tenderness when applying any pressure to the site.Ī: Nothing that appears to aggravate this condition Skin: History of skin disease (eczema, psoriasis, hives), pigment or color change, change in a mole, excessive dryness or moisture, pruritus, excessive bruising, rash, or lesion. General Overall Health Status: Weight gain or loss, fatigue weakness or malaise, fever, chills, sweats or night sweats. Instructions: Highlight the symptom if present, then complete analysis for each symptom using OLDCART: (O = Onset, L = Location, D = Duration, C = Characteristics, A = Aggravating Factors, R = Relieving Factors, T = Treatment). Genogram (3 generations to include parents and grandparents) – May complete on a separate page This information should be what you transfer onto your Genogram. Then state that they deny all other diseases listed (for those diseases not in the family history). List all family members here, along with whatever diseases they have. (This can be food, medication and/or seasonal allergies)Ĭurrent Medications (prescription and OTC įAMILY HISTORY (coronary artery disease, high blood pressure, stroke, diabetes, obesity, blood disorders, breast/ovarian cancer, colon cancer, sickle-cell anemia, arthritis, allergies, alcohol or drug addiction, mental illness, suicide, seizure disorder, kidney disease, TB) (6 points) Last Examination Date (physical, dental, vision, hearing, ECG, chest x-ray, mammogram, colonoscopy, serum cholesterol) If the surgery was done as an outpatient procedure, then state that here only. If Surgery required an overnight stay in the hospital, then copy this in the hospital section as well. Surgeries (year type of surgery, date, name of surgeon, name of hospital, how person recovered) Hospitalizations (year cause, name of hospital, doctor, how the condition was treated, how long the person recovered) Serious or Chronic Illnesses (asthma, depression, diabetes, hypertension, heart disease, HIV infection, hepatitis, sickle-cell anemia, cancer, seizure disorder Patient states that it was negative.Īccidents or Injuries (year auto accidents, fractures, penetrating wounds, head trauma-especially if associated with unconsciousness, burns complications) For example: Patient states that they received their TB test within the last 5 years but cannot recall the exact date. If patient cannot recall the date, they can just provide an approximate date/age. Immunization Dates (influenza, pneumococcal, shingles date of last tetanus and date and results of last TB test) (This section will be how you address the ANALYSIS OF DATA on page 6)Ĭhronological account – give a thorough history (like an OLDCART)Ĭhildhood Diseases (age measles, mumps, rubella, chickenpox, pertussis, strep throat, rheumatic fever, scarlet fever, poliomyelitis)Įx: Measles early childhood (or their age, if they remember) Present Health: (chronological account of “I am helping (insert your name here) with their school project” Reason for Seeking Care: (“In quotes”) (2 points) Source of Information AND Reliability: ex: Patient and appears to be reliable Insurance Coverage: Only need to know if they have health insurance – do not need policy name or number Name (Initials): Age: Gender: Marital Status: