Please list all the medical problems: Please list all the surgeries that you had: Please list all the current medications: List any drug ALLERGIES:
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- Hilary Marshall
- 8 years ago
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2 Patient s Name: Date of Service: Please list all the medical problems: Please list all the surgeries that you had: Please list all the current medications: List any drug ALLERGIES: Social History: Family History of any related medical problems: Review of Systems: (Circle if positive) GENERAL: Weight change Dizziness Fatigue Sleeping difficulty Fever SKIN: Rash Lesions HEADACHE: Decrease hearing Decrease vision Nasal discharge NECK: Pain spasm swallowing BLOOD; Bleeding (if yes specify site) LUNGS: Shortness of Breath Cough Vomiting HEART: Chest Pain Palpitations ABDOMEN: Abdominal Pain Nausea Vomiting KIDNEY: Pain on urination Blood in the urine ENDO: Heat intolerance Cold intolerance NEURO: Numbness Tingling Weakness BACK Pain Spasm OTHER: Anxiety Depression 2
3 ACTIVITIES OF DAILY LIVING COMMONLY MEASURED IN ACTIVITIES OF DAILY LIVING (ADL)* Name of Applicant: Date: CATEGORY OF APPLICANT HAS DIFFICULTY WITH: (MARK WITH AN X BELOW AND EXPLAIN WHERE INDICATED) Without With Some With Much Mostly unable to Do 1. Self-Care, Personal Hygiene (Urinating, defecating, brushing teeth, combing hair, bathing, dressing, oneself, eating) Take a shower Take a bath Wash & dry body Wash & dry face Turn on/off faucets Brush teeth Get on/off toilet Comb/brush hair Dress self Put on/off shoes/socks Open carton of milk Open a jar Lift glass/cup to mouth Make a meal Lift fork/spoon to mouth (Bladder and bowel function difficulties: incontinence, retention, constipation?) 2. Physical Activity (Standing, sitting, reclining, walking, climbing stairs) Stand Sit Recline Rise from a chair Get in/out of bed Climb flight of 10 stairs Work outdoors Light housework Shop/do errands Carry groceries Lift 5 lbs. Lift 10 lbs.. Lift 20 lbs. Lift 30 lbs. Walk Care for children or parents Engage in hobbies (music or crafts, etc.) indicate hobby: (eating/chewing difficulty: TMJ?) Form ADL (Rev. 02/09/06) 3
4 CATEGORY OF 3. Communication (Writing, typing Seeing, hearing, Speaking) APPLICANT HAS DIFFICULTY WITH: (MARK WITH AN X BELOW AND EXPLAIN WHERE INDICATED) Without With Some With Much Write a note Type a message on a Computer/typewriter See a television screen Use a telephone Speak clearly Hear clearly Mostly unable to Do 4. Non-specified Hand activities (Grasping, lifting, tactile, discrimination) 5. Sensory Function (Hearing, seeing, tactile feeling, tasting, smelling) 6. Travel (Riding, driving, flying) Pick up a small item Turn a knob on a door Write with a pen/pencil Steer wheel of car Feel what you touch Taste what you eat Smell what you eat Get in/out of a car Drive a car Ride in a car Fly in a plane Ride a bicycle 7. Sexual Function Orgasm, ejaculation, lubrication, erection) 8. Sleep (Restful sleep, nocturnal sleep pattern) Engage in sexual activity Describe specific difficulty: (Orgasm, ejaculation, lubrication, erection?) Get to Sleep Sleep through the night Have restful sleep Feel refreshed after sleep Describe specific difficulty: (teeth grinding at night, excessive daytime fatigue, irritability, etc.) Form ADL (Rev. 02/09/06) 4
5 The Spine and Orthopedic Center EPWORTH SLEEPINESS SCALE Patient Name (Nombre): DATE (Fecha): Please rate your likelihood of falling asleep in the following situations: Por Favor indique la facilidad con que le entra sueno en las sigulentes situaclones: Never Sometimes Most Times Always Nunca Algunas Veces Casi Siempre Siempre Sitting and Reading Sentado y leyendo Watching Television Mirando la television Sitting in a Public Place Sentado en lugar publico Riding as a passenger for an hour Yendo de pasajero por una hora Taking an afternoon nap Tomando una siesta en la tarde Sitting and talking to someone Sentado y hablando con algulen Sitting after a non-alcohol lunch Sentado despues de comer, sin tomar alcohol Stopped in traffic Parado en trafico Total /24 Patient Signature (Firma) Class 1 Class 2 Class 3 Class 4 1%-9% Impairment of the 10%-29% Impairment of the 30%-69% Impairment of the 70%-90% Impairment Whole person Whole person Whole person of the Whole person Reduced daytime alertness; Reduced daytime alertness; Reduced daytime alertness; Severe reduction of daytime Sleep pattern such that individual interferes with ability to perform ability to perform activities alertness; individuals unable Can perform most activities of some activities of daily living of daily living significantly limited to care for self in any Daily living situations or manner 5
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PATIENT INFORMATION Name Date of Birth Social Security # XXX-XX- Address Apt. # City State Zip Home Ph# Cell Ph# Driver s License # E-mail address: Race: Afro-American Am-Indian American Asian Black Caucasian
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As you begin the process of alkalizing and granting the body more energy for cleansing itself (and also for regeneration), many symptoms and seemingly adverse reactions can occur throughout this process