Pre-visit Medical/Mobility Questionnaire

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PRE― Ⅶ SIT Ⅷ
DICAL QWSTIO幽 俎 駆
NSIP1/‐ σrFθ ハタ
is lengthy, it is
h,ealth. o,,*:::^,,:is form
medical
your
abol,t
questions
greatly assist
Please ansl.er the folloluing
before your appointntent will
in?o,nation
,h'i,
co*ptriing
designecl to be very t';ir:rrin.
together'
exam ancllest use your time
the doctor to be focused in you.
Date of Evaluation:
Narlle Of Patienti
ient,please fillin thiS bOX:
lf yOLl are COmpleting thiS fOr7n On behalf Ofthe pat
'ATIENT
DEMOGttPHICS
APT.
STREET:
STATE
cITY:
ZIP:
cell:
PHONE (Home):
AGE:_____ SEX:
DATE OF BIRTH:
Who is Your Priroary
doctor? Dr'
Cffit
Address:
Phone number:
(
Fax Number:
(
.t
**t t"*'t
PrimarY PhYsician
□
Male
□ Female
PRESE NTDiG PROBLENI
WIho refeπ ed you to tlle ⅣIcmo宣 /Cli五 c?
May we contact the refen'ing physician?
o No O Y es
Please briefly describe what memory problem(s) you are experiencing:
Did these changes have an abrupt onset (for example,
Did these changes have a gradueal onset (for
normal one day and then problems the next)?
example, slowly worsening over
Please describe when the problems started, and the
i
time)? tr No A
No O
Y
Yes
es
pattern of the problems up until the present:
Have you noticed a:ry of these additional symptoms? Please check those that apply to you and
provide an example in the space below (for example: if you answer yes to being easily distracted, your
example may be "difficulties watching fullTV shovl').
A.
Attention
Yes
tr No o Y es
o No
O
Easily distracted
Difficulties staying on task
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B
Memory
C
No n Yes
Asking same question repeatedly
CNoaYesDifficultieswithmakingorkeepingappointments
C No C Y es
C No O Y es
D No O Y es
C.
,'
Forgetting recent conversations
Forgetting why you went into room
Forgetting where things are in the
kitchen
t
Laneuage
iNooYesCan,tthinkoftherightword(..tipofyourtongue,'experience)
StoPPed reading
CI No O Y es
fl No O Y es Mispronouncing or usi:rg wrong words
! No O Y es Handwriting has deteriorated
trNoSYesTroublerecaiiingnamesoflongtimeacquairrtances
D. Visuospatial finCtiOn
□
No
口
yes
口 No EEl yes
□
□
□ yes
No
No O yes
CO」
hSed or disOriented h storeS Or mallS
Getting loSt easily evcn on familiar routes
Trouble flnding the car in the parking lot
Dif「 lCulty
driVhg― ■umber of accidents and WhCni
3 of13
E.
Executive Function
3 No 3 Y es
O No O Y es
c No 3 Y zs
tr No O Y es
Feeling disorganized
PersonalitY changes
gatherings
Embarrassing or inappropriate behavior in social
Difhcuities with hygiene or toilet use
oNoaYesDifilouitieswithnegativeevaluationsatwork
F.
Praxis
o No A Yes Difficulties using household items
etc')
o No 3 Y es Trouble dressing (wrong apparel for the weather, shirt inside out'
G. Vision
O No O Y es
O No O Y es
Bluned vision
GroPing for door handles
Time and Leisure: When alone, what do you do?
wouldyouconsidertheseactivitiesachangefromwhatyouusedtodo?SNoOYes
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PAST MEDlCAL HISTORY
Please check all lnedical conditions that you have
or have had in the Past:
Ⅱ.
HEART PROBLENIS
none
none
a)
00
b)0
0 Cataracts
b) 0
Glaucoma
0 Other, specify:
IEI.LUNG PROBLEⅣ
>[t
Heart failure
High blood pressure
C)0
d)0
C)0
0 Macular degeneration of the eYe
d) 0 Hearing losslhearing aid
C)
C)
Heart attack:
Lregular heart beats(aΠ hメhnias)
Other, specify:
Ⅳ
IS
.BONE&JOINTT PROBLEMS
nonc
■one
a)
→ 0 Asthla
b) 0 Bronchitis
C)
0 EInphysema
d)
0 Other,specl力
:
俎 hitis
0
b) 0
Osteoporosis
C)
Gout
0
d) 0
Fractured hip/wrist/spine
力θ
″θ
ツ
カメ
ε
ルシ
″ε
e) O
Other, specifY: `'ノ
`ど
硼 N_ARY TRACT
PROBLE■ lIS
ヽ■.KEDRTEY&硼
V. GLAND PROBLEPIS
none
al
0 Diabetes
b)
Thyroid (overactive / high)
0 Thyroid (underactive / low)
0 Other, specify:
C)
d)
none
0
→ 0
Kidney disease
b) 0
Prostate discasc
C)
Frequent bladder or kidney infections
0
d) O
U血 ary
C)
Other, specify:
O
\Atr.
1/ lI.GASTROIRTTESTINAL PROBLEIVIS
０
０
０
０
→ 0
0
b)
-none
NER.VOUS SYSTEM PROELEMS
Stroke
-none
C)
0
d)
0
Dementia or Alzheimer's Disease
Parkinson's Disease
Epilepsy or Seizures
Hepatitis
C)
0
Head injury/concussion
Polyps
D
0
Other, specify:
Heartbum I lnatal hernia
Diverticulosis
Liver disease/Cirrho sis
０
０
０
０
の り ＞
ｃの ＞
ｃ０ ９ Ｄ
Ulcers
incontinence
Gallbladder disease
Other, specif':
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none
a) 0 Allergies 6PnrrfY)"
b)
0
nernia
電
′
C)
0
Herllla
d)
0 ThrombOSiS o100d C10tS)
e) O
Cancer (ofwhat)"
D O
Depression
g) 0｀
(specifv):
Sexual function problems
DO
Other; sPecifY:
-
additional Page, if needed'
List surgeries (oPerations)' Use
List other
ho sPitalizations'
Use additionai Page,
if
needed'
EASON
Do you have anY drug allergies?
爾
o No A Y es: sPecifY below
OF DRUG
6 of13
List
a1i
& natural products)
medicines that you use. (prescription, non-prescription
N船
1
500 ntg
Example; Tylenol
FAⅣILY
Hoヽ「OFTEN PER DAY
STREXTGTH
凪 OF卜 /EDICATION
pill 3 times a daY
HISTORY
conditions? (check all that apply)
Have any members of your family had any of the following
tr No c Yes DementiaorAlzheimer'sDisease
tr No O Y es Diabetes
tr No o Y es DePression
口
□
□
No
No
No
o Y es
Heart disease
C Yes
C Yes
Stroke
Cancer:-
To be certain that weive cOVered everything,please check if you haVe had any ofthe fol10Wing sフ
or problCms DLIRING THE LAST 3 MONTHS:
I.GENERAL PROBLEⅣ
II.
IS
EYE PROBLEMS
_none
＞
↓ Ｄ ＞
ｃ の ｃ つ り
a) o Trouble seeing
b) O Eye Pain
c) 0 DrY eYes
o Weight loss -none
o Weight gain
0 Fevers
o Chills
0 Sweats
O Cold or flu
O Change in aPPetite
7 of13
mptoms
Ⅲ
r'Y.
` EARS,NOSIE,WIOUTH&THROAT
I.NEA-R.T
PROBLEⅣ IS
--none
none
a) O Chest pain or tightness
b) O Rapid or iriegular heartbeat
c) O Swelling of feet
a)O TIOuble hearhg
b)O Ear pah oritching
C) O Sinus trouble
d)
O Nose blecds
V.
C)O SOrethrOat
a)
b)
c)
d)
0 0 Teeth prOblems
g)O HOarseness
り O MOuth SOres
ぅO Allergies
ヽ■.
PR.OBLEMS
LUAIG PROBI-,EMS
none
O Persistent cough
O Coughing up blood
0 Wheezing
O Difficulty breathing or shortness of
breath
DIGESTION PROBLEPIS
none
PROBLENIS
1/ EI.BO剛 &JOM
nonc
a)O Dttculty swallowhg
b)O Frequent indigestion/stomach ache/
heartbum
c)O Frequcnt nausca or vorruthg
d)O Change in bowel habits
‐
a)O
Leg pah on waLking
b)O Back orneck pah
C)0
C)O Black bOwel movement or bleedhg ttom
」Oint pah or sti艶 ■ess
d)O Foot problems
recturn
o O Frequent diarrhea
C)O Falls
g)O Persistent constipation
VEE.BRAIN&NERVOUS SYSTEⅣ
PROBLEⅣ IS
I
IX・
PI100D PROBLER/11S
none
nonc
→ O Frequent headaCheS
b)O Frequent dizzy spells
a)o Depression
b)0 極 ieサ
c)O Delusions/halluchations
C)O PaSSing out or fainting
X.
d)O PrOblems with sleep
e)O
o o
g)O
h)O
GYNECOLOGY PROBLEM[S
nonc
Paralysis,leg or allll weakness
Numbness orloss offcclingS
P00r memory or diliculty lhhhng
TremOr Or shaking
0 0 Vaginalbleedhg
b)O Vaginal discharge
C)O Breast lmps or disCOmfort
8 of13
.翻
刈
a)
b)
c)
d)
e)
XΠ .SKⅢ ヽPROBLENIS
NEY&URttNARY PROBLEPIS
_none
none
a) O Rash
b) 0 Sores
c) 0 Itching
O Urination at night. # of times:
O Frequent urination
0
o
0
Painful
urination
Difficulty starting or stopping urination
Loss of urine cr getting rvet. If yes, 6 or
more times in last
xlrx'
year?
a) 0
b) 0
a) 0
HEALTn
IvmscELLANEous PR'OBLEMS
-.none
Excessive thirst
Feel too hot or too cold
Problems with sexual function
ⅣυttNTENANCE
Have you ever had aII cxarmnation ofyour bowel Ⅵ′
ith a scope?
□ No□ yes:when was your mostrecent∈ _sigmOidoscopy/__colonoscopy)?_
Have you had a hearmg test withh the lastか
″o years?
口 No EEl yes
□ No
Have you had an eye exam v√ ithin the past year?
□ ycs
ln the past 12 months,havё you had a test for blood ill your stoo1 6物
□
No
rθ
θθ
α″
ルθ
777の ?
赤α
口 yes
IIave you seen a delltist in the last year?
口
No
□ yes
Have you ever had thc Pneumovax vaccine(a ShOtto prevent pneumo」 a)? 口
No
□ yes
lf``yes,"in what ycar did you have yourlast Pnetlmovax vacche?______(year)
Have you ever had a tetallus shot? EEI No
口 yes
lf``yes,"in what year did you have your lasttetanus shot?_____け
Car)
Have you had a flu shotthis scason,October― February(■ ot applicable Marё h― September)?
口
No
□ ycs
Do you always wear a seatbeit when you ride in a c釘
?
□
No
口 yes
Do you cllrrently participate in regular act市 iサ tO improve or maintah your physical fltness?
C No O Yes:
w-hat
activity do you do cun-ently:
9 of13
(yCar)
Do you havc any probleⅡ ls with fallhg?
tEI No
□ yes
Aご e you afraid of falling?
□ No
El yes
Have you had a fall in the past year? □
No
口 yes
No
口 yes
lf you had a fall,did you have a
problem geting up by yourselP
Ⅳ回 N
ONLY:
□
l
Have you ever had a prostate exam(reCtal exam)?
lf“ yes,"when
yes
EI No □
t
did you have your most recent prostate cxttp______(ycar)
yes
Have you CVer had a blood testto look br,ancer ofie prostate(PSA)? EI No 口
llf``yes,''when did you have this IIlost recent blood test?_______(year)
WON4EN ONI.Y:
Do you perfon'n breast self-exam @SE) once a month? CI
Have you ever had a mammognam?
D No
No J
Yes
CI Yes:
(month/year)
Have you had a hysterectoney (surgical removal of the
If "no," have you
uterus)?
ever had a Fap Smear / pelvic examination?
Please check the appropriate response for each question below:
:
With whom do you live?
O
Alone
Spouse or partner
Child or other family member
Others, not family-specifY:
Which of the foliowing best describes your residence?
O
0
o
0
O
0
0
O
No D Yes:
(montb/year)
SOCIAL IilST'ORY
0
0
o
tr No O Yes
Single-family house
Condo or apartment
Live with another in their home, condo or apartment
Retirement hotel
Board and carelresidential care facility
Nursing Home
Other, specify:
10 of13
Are you currently:
O Manied (# of previous man'iages:
O Single i Never manied
O Divorced / Separated
O Living with Significant Other
---)
How many children do you have?
Are you in regular contact with'your chiidren? C
No 3 Y es
How much school did you complete? (where did you attend school?
O Less than 6th grade
O Less than high school graduate
0 High schooi graduate
O
Some college
0
0
College graduate
More than college graduate
O
Postgraduate degree
r
-US -abroad)
What has been your principal occupation?
Are you currently:
O
Retired / not
O Worki:rg part-time
working
0
Working full-tirne
Do you employ someone to provide care or help you in your home? C
If "yes," how
many hours a
day?
Is this sufficient to meet your
needs?
Y
es
Do you get help from a family member or friend in your home?
If "yes," how
many hours a
day?
Is this suffrcient to meet your
needs?
o No
Do you provide care for a family member? D
a
vehicle? C
No o
Y
o No o Yes
How many days a week?
O Y es
Who would you call if you were sick and needed help?
Do you drive
No c
How many days a week?
o No o
No O Y es
es
1l of13
O Widowed
Yes
Do you drink alcohol (such as beer, rvine, r,odka, whiskey, gin)?
0 Daily
0
o Almostdaily(4to6rimesaweek) o
Less than 1 time a r,veek
O Never
lto3timesaweek
If you drink alcohol, has anyone ever been concerned about your drinking?
Have you ever smoked
cigarettes? O No e
If "yes," Ere ysp now smoking? tr
No o
yes
many years ago did you
How much did you
⊇LANNENG
smoke?
,
yes
How many years have ),ou smoked ?
If "no," how
c No o y es
How much do you
smoke?
packs per day
quit?
For how many years did you smoke?
-packs per day
FOR FUTURE HEALTH C側
Do you have a medical Durablc Po、 ver ofAttomey?
□
No
□ yes
Do you have alivLg will? EI No 口 yes
Pleasc hdicate ifyou nced help■ rith ally ofthe followhg,and if so,whO helps you.
TASK
DON'Tヽ田ED I― ELP
Feeding yourself
Getting from bed to chair
Getting to the toilet
Getting dressed
Bathing
Using the telephone
Taking your medicines
Preparing meals
Managing money / finances
Doing laundry
Doing housework
Grocery shopping
DJvhg
Doing "handyman" tasks
Climbing stairs
Getting to places beyond walkins
12 of13
NEED HELP
ヽ彊 O
HELPS
Do you
harze any other health
D No A
problems tha[ you u,ou]d like your doctor to know about before your visit?
Yes:
COⅣ PLETION OF FORNI
IS FORⅣ I MUST BE SIGNED BELOW BY THE PATIENT.NO PROXY SIGNATITRES PLEASE.
TI■
Print Name
Date
Signature
We appreciate your help
ill
cocapleii:Eg this
form. Thank you.
13 of13