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10 Cards in this Set
- Front
- Back
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SKIN/HAIR/NAILS
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a. Have you had any past skin disease?
b. Have you noticed any changes in skin color or pigmentation? c. Have you noticed any changes in a mole? d. Have you noticed any excessive skin dryness or moisture? e. Have you noticed any recent hair loss? f. Have you noticed any change in your nails? |
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EYES
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a. Have you had any difficulties with your vision, including blurring?
b. Have you had any history of crossed eyes? c. Have you noticed any redness or swelling in your eyes d. Have you noticed any watering or tearing of your eyes? e. Have you ever had an injury or surgery to your eyes? f. Have you ever been tested for glaucoma? g. Do you wear glasses or contact lenses? |
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NOSE/MOUTH/THROAT
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a. Have you noticed any nasal discharge?
b. Have you noticed any change in smell? c. Do you have nosebleeds? d. Do you have allergies or hay fever? e. Do you have any sores in your mouth or on your tongue? f. Do you have sore throat? How often? g. Do you have any difficulty swallowing? |
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THORAX/LUNGS
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a. Do you have a cough?
b. Do you have any shortness of breath? c. Are there any living or work conditions that may affect your breathing? d. Do you have any chest pain with breathing? e. Do you smoke? f. Have you had a TB skin test? Chest x-ray? Flu vaccine? g. Do you have any history with lung diseases? |
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HEART/NECK VESSELS
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a. Do you ever feel any tightness in your chest?
b. Do you ever seem to tire easily? c. Do you ever notice your face turning blue or ashen? d. Do you ever frequently awaken to urinate at night? e. Do you have any history of heart disease? f. Do you have any family history of heart disease? |
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PERIPHERAL VASCULAR SYSTEM/LYMPHATIC SYSTEM
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a. Do you ever experience any leg cramping? Where?
b. Have you noticed any swelling in your legs? c. Have you noticed any sores or lesions on your arms or legs? d. Have you noticed any swollen glands? e. What medications are you taking? |
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NEUROLOGICAL
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a. Have you had any frequent or unusually severe headaches?
b. Have you ever felt any dizziness? c. Have you ever had convulsions? d. Have you noticed any tremors or your hands or face? e. Have you noticed any weakness in any body part? f. Do you ever have problems with coordination? g. Have you noticed any numbness or tingling in any body part? |
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ABDOMEN
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a. Have you noticed any change in appetite?
b. Are there any foods you cannot tolerate? c. Have you had any nausea or vomiting? d. How often are your bowel movements? e. Any past history of GI disease? f. Can you tell me what you ate in the last 24 hours (24 hour recall)? |
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MUSCULOSKELETAL
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a. Have you noticed any stiffness in your joints?
b. Have you noticed any heat or redness in your joints? c. Do you have any limitations of movement or range of motion? d. Have you noticed any bone or joint deformities? e. Have you ever had any bone fractures or trauma? f. Do you have any history of arthritis? g. Do you have any problems with the activities of daily living, like bathing or dressing? |
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ANUS/RECTUM/PROSTATE
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a. Have you ever had any black or bloody stools?
b. Are you taking any medications? c. Have you noticed any rectal itching or hemorrhoids? d. Do you have any family history of colon/rectal polyps or cancer? e. Can you describe the usual amount of fiber you get in your diet? What foods do you eat that contain fiber? |
