Medical History Form - Excel - Excel

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Medical History Form - Excel - Excel Powered By Docstoc
					                            Initial history and physical evaluation
      (To be sent to Columbia Asia by the patient/ attenders for taking medical opinion)
Name of the patient:
Age:
Sex:
Present complaints:

History of present illness:

Past medical and surgical history:

Medication list:

Social history:

Alcohol use:                  Alcoholic                                      Non-alcoholic
Smoking tobacco, others:      Smoker                                         Non-smoker
Drug abuse:                                                Yes                                     No
Sexual history:
Allergy to any medication
or food:
Family history:

Review of systems:
  1. Any history of headaches, blurred vision, tinnitus, vertigo:                            YES    NO
  2. Any history of ulcer in the mouth, nausea, vomiting:                                    YES    NO
  3. Any history of hoarseness of voice, cough, hemoptesis, hematemesis:                     YES    NO
  4. For females any history of lumps in the breast, discharge from nipple:                  YES    NO
  5. Any history of chest pain, shortness of breath, palpitations:                           YES    NO
  6. Any history of abdominal pain, distension:                                              YES    NO
  7. Any history of hematuria, Sexual problems:                                              YES    NO
  8. For female patients, any history of menstrual disturbances, Last menstrual period:      YES    NO
  9. Any history of joint and muscle pains:                                                  YES    NO
PLEASE SPECIFY, IF YOUR ANSWER TO POINTS 1-9 IS YES


TO BE FILLED BY THE PATIENT'S DOCTOR, if available
VITALS
Blood pressure
Pulse
Temperature
Oxygen saturation
Respiratory rate

Systemic examination:
CVS:
RS:
Abdomen:
CNS:
Extremity:

REPORTS ATTACHED TO GET THE MEDICAL OPINION FROM COLUMBIA ASIA (use hyperlinks)
LABORATORY

RADIOLOGY

FINAL ASESSMENT OF THE PATIENT BY THE TREATING DOCTOR AND REASON FOR REFERRAL
Name of the physician completing the form:
*This form to be filled by the physician at the country of origin*

				
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posted:9/1/2012
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