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21 Cards in this Set
- Front
- Back
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General Impression |
Usual weight, Weight change, Weakness, Fatigue, Fever |
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Rashes Lumps Itching Dryness Color changing Hair Nails |
Skin Condition |
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Head Condition |
Headaches Head injury - ( MOI) Mechanism Of Injury, Cause of it |
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VisionCorrective Lenses use, what typeLast Eye ExamPainRednessTearingDouble vision |
Eye Condition |
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Ear Condition |
Hearing Tinnitus (ringing in the ears) Vertigo( dizzy spells) Pain, ear ache Infection Discharge |
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Frequent Colds Nasal stuffiness Hey fever Atopy Nose bleeds Sinus trouble |
Nose and Sinuses |
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Mouth and Throat |
Last Dental exam Teeth and gums Sore tongue Frequent sore throat Hoarseness |
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Neck |
Pain Lumps |
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Self exam Pain Lumps Nipple discharge |
Breast |
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Coughing Sputum ( color, quantity) Hemoptysis() Wheezing Asthma Bronchitis Pneumonia Pleurisy () Tuberculous ( last PPD) Chest X-ray ( CRX) |
Respiratory |
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Cardiac |
Heart trouble HTN Rheumatic fever Heart murmurs Dyspnea Orthopnea Edema Chest pain Palpations Last EKG |
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Trouble swallowing Heart burn Appetite Nausea Indigestion Constipation Diarrhea Abdominal pain Food intolerances Vomiting ( blood)Indigestion ConstipationDiarrheaAbdominal painFood intolerancesExcessive belching or fartingHemorrhoidsJaundiceLiver or gallbladder trouble Excessive belching or farting Hemorrhoids Jaundice Liver or gallbladder trouble |
Gastrointestinal |
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Gastrointestinal |
Frequentcy in BM last BM Change in routine and habits Rectal bleeding Tarry stool |
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Frequentcy in urination Polyuria Nocturia Dysuria Hematuria Urgency, hesitancy, Incontenice Urinary infections Renal calculi ( stones) |
Urinary |
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Musculoskeletal |
Joint pain Bach ache Stiffness Arthritis |
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Description of Location Swelling Redness Pain Weakness ROM ( Range of Motion) Past injury Treatment |
Musculoskeletal |
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Neurological |
Fainting Blackout Seizures Paralysis Weakness Numbness Tingling Tremors Memory |
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Mood Affect Nervousness Tension Depression Anxiety Attitude Past care |
Psychiatric |
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Endocrine |
Thyroid trouble Heat and cold intolerances Excessive sweating Thirst Hunger Urination Diabetes |
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Anemia Easy bruising Bleeding Past blood transfusion and reactions |
Hematologic |
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Genito- Reproductive MALE |
Discharge |
