HealthSouth � Tallahassee by 096T1Ev


									                       Tallahassee Pulmonary Sleep Questionnaire
Name__________________________________________________                        Age_________        Date________________

Date of Birth_________________           Sex______        Height _____ ft _____ in          Weight_______ lbs

Neck size________ inches (If known)                       Body Mass Index (BMI)________ (If known)

Address____________________________ City _____________________ State____________________

Phone(s)____________________________(home) _____________________(work) ____________________(cell)

Email _______________________            Patient SSN__________________            Gender__________________________

Marital Status _______________________ Race__________________                      Ethnicity________________________

Preferred Language______________________                Primary Insurance Company______________________________

Secondary Insurance Company______________________                   Self Pay______________________________

Referring Doctor_____________________________                 Primary Care Doctor______________________________

Reason for today's visit:_______________________________________________________________________
I understand I am responsible for my bill at this office, regardless of the action taken by the above insurance companies, I
understand failure to pay any monies owed the account will be processed through a collection agency. I authorize the release of any
medical information necessary to process claims at this office, and I also request payment to myself or to the party who accept
assignment. My physician has advised me that based on Medicare’s guidelines, some services which my physician deems necessary
may be denied by Medicare as not medically necessary. Therefore, I acknowledge and accept liability for payment of these services.

        Please verify with your insurance company if authorization is required for services.
        I acknowledge that I have received your Notice of Privacy Practices.
               It is okay to leave message on my Home Phone, Cell Phone, Answering Service, TEXT (SMS) on my cell phone.
               It is okay to call place of employment.
               It is okay to mail appointment reminder cards to my home address of record.
               It is okay to send appointment reminders and my personal health information through a secure web portal.
               Do not discuss my healthcare with anyone.

You may discuss my health care information, schedule or reschedule appointments with the following people ONLY.

Name ___________________________              Phone__________________            Relationship________________________

Name ___________________________ Phone__________________                         Relationship________________________

Name ___________________________ Phone__________________                         Relationship________________________

I give permission for Tallahassee Pulmonary Clinic to view my prescription history at Pharmacy.

Date ___________________________              Signature ___________________________

                                        DOB:                                Place Patient                          PAGE 1 OF 9
                                        FIN:                                 Label Here
                                             Tallahassee Pulmonary Clinic
                                                        Notice of Privacy Practices
                                              THIS INFORMATION.
                                                   PLEASE REVIEW IT CAREFULLY.
The Health Insurance Portability & Accountability Act of 1996 (“HIPAA”) is a federal program that requires that all medical records and
other individually identifiable health information used or disclosed by us in any form, whether electronically, on paper, or orally, are kept
properly confidential. This Act gives you, the patient, significant new rights to understand and control how your health information is used.
HIPAA provides penalties for covered entities that misuse personal health information.
   As required by HIPAA, we have prepared this explanation of how we are required to maintain the privacy of your health information
and how we may use and disclose your health information.
   We may use and disclose your medical records only for each of the following purposes:
Treatment, payment and health care operations.
      Treatment          means providing, coordinating, or managing health care and related services by one or more health care providers.
          An example of this would include physical examination.
      Payment means such activities as obtaining reimbursement for services, confirming coverage, billing or collection activities,
          and utilization review. An example of this would be sending a bill for you visit to your insurance company for payment.
      Health care operations           include the business aspects of running our practice, such as conducting quality assessment and
          improvement activities, auditing functions, cost-management analysis, and customer service. An example would be an internal
          quality assessment review.
We may also create and distribute de-identified health information by removing all references to individually identifiable information.
 We may contact you to provide appointment reminders or information about treatment alternatives or other health-related benefits and
services that may be of interest to you.
  Any other uses and disclosures will be made only with your written authorization. You may revoke such authorization in writing and we
are required to honor and abide by that written request, except to the extent that we have already taken actions relying on your
  You have the following rights with respect to your protected health information, which you can exercise by presenting a written request
to the Privacy Officer:
          The right to request restrictions on certain uses and disclosures of protected health information, including those related to disclosures to
           family members, other relatives, close personal friends, or any other person identified by you. We are, however, not required to agree to
           a requested restriction. If we do agree to a restriction, we must abide by it unless you agree in writing to remove it.
          The right to reasonable requests to receive confidential communications of protected health information from us by alternative means or
           at alternative locations.
          The right to inspect and copy your protected health information.
          The right to amend your protected health information.
          The right to receive an accounting of disclosures of protected health information
          The right to obtain and we have the obligation to provide to you a paper copy of this notice from us at your first service delivery date.
          The right to provide and we are obligated to receive a written acknowledgment that you have received a copy of our Notice of Privacy
  We are required by law to maintain the privacy of you your protected health information and to provide you with notice of our legal duties and
privacy practices with respect to protected health information.
  This notice is effective as of April 14, 2003, and we are required to abide by the terms of the Notice of Privacy Practices currently in effect. We
reserve the right to change the terms of our Notice of Privacy Practices and to make the new notice provisions effective for all protected health
information that we maintain. We will post and you may request a written copy of a revised Notice of Privacy Practices from this office.
  You have recourse if you feel that your privacy protections have been violated. You have the right to file a formal, written complaint with us at
the address below, or with the Department of Health & Human Services, Office of Civil Rights, about violations of the provisions of this notice or
the policies and procedures of our office. We will not retaliate against you for filing a complaint.

Please contact us for more information:                                 For more information about HIPAA
Lynn Streetman                                                          or to file a complaint:

1401 Centerville Road, Suite G -02                                      The U.S. Department of Health & Human Services Office of Civil Rights
Tallahassee, FL 32308                                                   200 Independence Avenue, S.W. Washington, D.C. 20201
(850) 878-8714                                                          (202) 619-0257
                                                                        Toll Free: 1-877-696-6775

                                                                                            Notice of Privacy Practice 1/28/03; Revised 03/01/07

                                              DOB:                                      Place Patient                                  PAGE 2 OF 9
                                              FIN:                                       Label Here
                                    TALLAHASSEE PULMONARY CLINIC
                                                   Disclosure of Ownership
Please be advised the following physicians own an investment interest in Tallahassee Pulmonary Clinic:

          Clifton J. Bailey, MD         J. Daniel Davis, MD             F. Ray Dolly, MD;
          David Y. Huang, MD             Praful B. Patel, MD            Carlos E. Campo, MD;
          John S. Thabes, MD             Joseph M. Gray, MD             Alberto L. Fernandez, MD
          Muhanad A. Hasan, MD

Pulmonary Function Diagnostic Testing and chest x-ray radiology
You are entitled to obtain the items or services for which you have been referred to Tallahassee Pulmonary Clinic from the provider or supplier of
your choice including Tallahassee Pulmonary Clinic.

The names and address of alternative sources of the items or services for which you have been referred are as follows:

             Tallahassee Memorial Hospital                                           Capital Regional Medical Center
            1300 Miccosukee Drive                                                   2626 Capital Medical Blvd.
            Tallahassee, Florida                                                    Tallahassee, Florida 32308

                                                   DISCLAIMER OF LIABILITY
                                        MULTIPLE RADIOLOGIC STUDIES AND LABORATORY VALUES

Multiple Radiological Studies
          In the event you or your physician provides a disk or other media that contains multiple radiology images or studies, Tallahassee
Pulmonary Clinic physicians will only review those images or radiologist reports related to the problem for which you are being treated by a
Tallahassee Pulmonary Clinic physician. In some cases, your Tallahassee Pulmonary Clinic physician will only review the radiologist report for
the radiological study performed related to the problem for which you are being treated, and will not review any other images contained on the
disk or other media. Tallahassee Pulmonary Clinic is not responsible for study results that have not been sent to Tallahassee Pulmonary Clinic or
brought by the patient.

Laboratory results
         In the event that you or your physician provides laboratory results contain multiple values, Tallahassee Pulmonary Clinic physicians will
review only those values related to the problem for which you are being treated by a Tallahassee Pulmonary Clinic physician. Tallahassee
Pulmonary Clinic is not responsible for laboratory values that have not been sent to Tallahassee Pulmonary Clinic or brought by the patient.

         By signing below, I acknowledge Tallahassee Pulmonary Clinic physicians will not review all radiologic images, studies, and reports on
the computer disk or other media, and will only view to the extent deemed medically necessary and appropriate the report issued by the
Radiologist and those specific images relevant to the treatment to be provided by Tallahassee Pulmonary Clinic.

          I acknowledge Tallahassee Pulmonary Clinic physicians will only review those laboratory values related to the medical condition that is
being treated by Tallahassee Pulmonary clinic.

           I acknowledge and agree that, I my successors and my assigns forever release from liability Tallahassee Pulmonary Clinic, its Board of
Directors, Shareholders, employees, independent contractors from any and all claims or demands from personal injury, sickness or death arising
out of any condition not reviewed by Tallahassee Pulmonary Clinic. To the extent the radiology report or laboratory analysis values indicate that
follow up should be initiated for any condition, injury, or illness that is not associated with the basis for the treatment provided by Tallahassee
Pulmonary Clinic, it shall be the responsibility of the patient and his or her primary physician to arrange for any need follow up or treatment. This
release is signed voluntarily, under no duress and with the full understanding of these terms.

Patient Signature: ___________________________                         Date ________________________

                                             DOB:                                      Place Patient                                PAGE 3 OF 9
                                             FIN:                                       Label Here
 Have you had a previous sleep study?           Yes     No If yes, what sleep center was it done at?_________________

         Check all that apply to you and your sleep. To the right of each problem, list how long this has bothered you?
            Loud snoring                     ____ years        Difficulty falling asleep           ____ years
            Excessive daytime sleepiness ____ years            Restless legs, usually at night     ____ years
            Excessive daytime fatigue        ____ years        Wake up frequently during the night ____ years
            Non-refreshing sleep             ____ years        Wake up early in the morning        ____ years
            Other sleep problems that are bothering you_______________________________________years_____


                                                        Never (N)    Rarely (R)    Sometimes (S)     Frequently (F)       Constantly (C)
Do you snore                                                                                           N      R       S        F     C
Snore so loudly that others complain                                                                   N      R       S        F     C
Snore so loudly that spouse sleeps in different room                                                   N      R       S        F     C
Suddenly wake up gasping for breath                                                                    N      R       S        F     C
Others say that you stop breathing during your sleep                                                   N      R       S        F     C
Fall asleep watching TV or sitting on the couch                                                        N      R       S        F     C
Fall asleep reading a book or magazine                                                                 N      R       S        F     C
Fall asleep at school or at work (e.g. at computer)                                                    N      R       S        F     C
Fall asleep involuntarily                                                                              N      R       S        F     C
Almost fallen asleep driving and veered off the road                                                   N      R       S        F     C
Had a motor vehicle accident due to falling asleep                                                     N      R       S        F     C
Feel tired during the day, especially after lunch                                                      N      R       S        F     C
Feel refreshed when you wake up                                                                        N      R       S        F     C
Feel like you get a good night’s sleep                                                                 N      R       S        F     C
Experience sudden attacks of muscle weakness when laughing, crying, or being highly emotional          N      R       S        F     C
Feel unable to move when half-awake and laying in bed (paralyzed when falling asleep or waking up)     N      R       S        F     C
Have vivid dream-like scenes while falling asleep (hypnagogic hallucinations)                          N      R       S        F     C
Have vivid dreams within a few minutes of falling asleep (hypnagogic dreaming)                         N      R       S        F     C
Remember your dreams                                                                                   N      R       S        F     C
Act out your dreams                                                                                    N      R       S        F     C
Talk in your sleep                                                                                     N      R       S        F     C
Walk in your sleep                                                                                     N      R       S        F     C
Eat in the middle of the night and are unaware of it                                                   N      R       S        F     C
Grind your teeth in your sleep                                                                         N      R       S        F     C
Experience creepy, crawling, aching feelings in both legs or simply have leg pains                     N      R       S        F     C
Have an urge to move legs associated with leg discomfort or leg pain                                   N      R       S        F     C
This leg discomfort worsens at night                                                                   N      R       S        F     C
This leg discomfort worsens at rest or when inactive                                                   N      R       S        F     C
This leg discomfort is relieved by movement                                                            N      R       S        F     C
Experience nocturnal leg jerking                                                                       N      R       S        F     C
Have indigestion or esophageal reflux at night                                                         N      R       S        F     C
Awaken with chest pain                                                                                 N      R       S        F     C
Awaken from sleep short of breath                                                                      N      R       S        F     C
Sweat excessively during the night                                                                     N      R       S        F     C
Have trouble sleeping when you have a cold                                                             N      R       S        F     C

                                        DOB:                                 Place Patient                            PAGE 4 OF 9
                                        FIN:                                  Label Here
                                               GENERAL SLEEP HABITS
1.    On average, how many hours of actual sleep do you get per night?__________________________________________

2.    What time do you usually go to bed on the WEEKDAYS?__________________WEEKENDS?___________________

      What time do you usually wake up on the WEEKDAYS?___________________ WEEKENDS?__________________

3.    On average, how long does it take you to fall sleep without a sleep aid?_____________ With a sleep aid?____________

4.    When you are asleep or trying to fall asleep, are you often disturbed by:

         Racing thoughts               Restless legs                 Pain                 Bed Partner               Light
         Anxiety                       Night sweats                  Heat                 Pets                      Noise
         Headaches                     Esophageal reflux             Cold                 Not being in your usual bed

5.    How many times do you typically wake up at night? ______________________________________________________

      How many of these times is it because you needed to urinate? _____________________________________________

      On average, how long does it take you to fall asleep after each awakening? ______________________________

6.    On average, how long do you stay in bed after waking up in the morning? __________________________________

7.    Do you work evening shift, night shift, split shifts, or rotating (variable) shifts?______________________________

      If so, what is your schedule? ________________________________________________________________________

8.    Do you usually: (Check all that apply)
         Sleep with someone else in your bed
         Sleep with someone else in your room
         Provide assistance to someone during the night (child, invalid, bed partner, animal)

9.    Do you wear a dental device when sleeping? If Yes, is it for sleep apnea ____________ or teeth grinding__________?
      If so, please provide dentist’s name:________________________

10.   Do you sleep on more than two pillows:         Yes        No           Please check if you have an adjustable bed:       Yes

11.   How many cups of coffee, tea, or other caffeinated beverages do you drink in 1 day? ________

12.   What time do you usually drink your last cup of a caffeinated beverage? ________

13.   Do you usually drink coffee or tea within 2 hours before going to bed?              Yes       No

14.   Do you do physical exercise before going to bed?          Yes         No

15.   Do you read before falling asleep?       Yes         No

16.   Do you take naps during the afternoon or evening?           Never          Seldom         Frequently

17.   Do you feel refreshed after a short (10-15 minute) nap?          Yes         No

18.   How do you feel after an average night of sleep?          Drowsy/Tired         Usually I feel good      Consistently I feel good

19.   If you feel drowsy or tired after an average night of sleep, how long do you feel this way?______________________

20.   Do you feel better during the?      Morning           Afternoon            Night

21.   How much weight have you gained in the last year?___________ lbs               Since the age of 18?___________ lbs

                                       DOB:                                      Place Patient                           PAGE 5 OF 9
                                       FIN:                                       Label Here
                                             PAST MEDICAL HISTORY
Check all that apply:
  High Blood Pressure                Esophageal Reflux/Hiatal hernia        Seizures/Epilepsy           Osteoarthritis
  Diabetes                           Sinus Allergies/Hay fever              Parkinson’s Disease         Rheumatoid arthritis
  Heart Disease/Heart Attack         Asthma                                 Dizzy/Blackout Spells       SLE (Lupus)
  Congestive Heart Failure           COPD (emphysema)                       Chronic back pain           Osteoporosis
  Heart murmur                       Pregnancy                              Chronic neck pain           Depression
  Atrial fibrillation                HIV/AIDS                               Chronic pain syndrome       Bipolar disorder
  Stroke                             Hypothyroidism                         Fibromyalgia                ADD or ADHD
  Elevated cholesterol               Strep throat before 21 years old       Mononucleosis (Mono)        Kidney Disease
  Cancer____________________         Cancer____________________             Other__________________     Liver Disease
                 Type of cancer                    Type of cancer           Other______________________________________
ENT Surgery or Surgery for Sleep Apnea:
   Tonsillectomy                      Adenoidectomy                       UPPP                               LAUP
   Nasal surgery                      Nasal septoplasty                   Turbinate reduction                Sinus surgery
   Gallbladder                        Appendectomy                        Hysterectomy                       Mastectomy
   Heart bypass surgery               Hernia surgery                      Ovaries removed                    Back surgery
   Gastric bypass surgery             Joint Replacement__________________________            ___________________________
                                                            Joint Replaced and Year              Joint Replaced and Year
   Any complications related to anesthesia or surgery?_________________________________________________________
Pneumonia Vaccine (Pneumovax)        No       Yes       Date last given____________________
Flu Vaccine    No       Yes Date last given__________________            Ever had swine flu vaccine?      No      Yes
Usual Childhood Vaccines (if applicable)     No      Yes
Drug                                                Dose                   Frequency              Purpose

    Medication                 Reaction                                    Medication                Reaction
_________________________________________________                   _________________________________________________
_________________________________________________                   _________________________________________________
_________________________________________________                   _________________________________________________

Preferred Learning Method:            Auditory        Visual       Written     Documentation
Preferred Language for Learning:      English         Other: _______________________________

                                      DOB:                                  Place Patient                      PAGE 6 OF 9
                                      FIN:                                   Label Here
                                                  SOCIAL HISTORY
1.        Have you ever smoked cigarettes?     Yes     No
2.        How much did you smoke?__________________________________ How many years?_______________
3.        If you have quit smoking, how many years ago did you quit?________years ago
4.        Do you drink alcohol?     Yes      No
5.        What do you drink?       Beer      Wine      Liquor
6.        How many alcoholic drinks do you have? ________per day ________per week ________per month
7.        Marital Status:          Married           Divorced           Single           Widowed
8.        What is your occupation?______________________________________________________________
9.        Is your present work situation satisfactory?__________ Is your present social life satisfactory?___________
10.       Has your sleep problem required you to cut back on social activity?____________________________
11.       Does your sleep problem disturb your sex life?_____________________________________________
12.       With whom are you living with now? (wife, husband, children, parents, etc. and their ages)
          _______________________________________               ________________________________________
          _______________________________________               ________________________________________
          _______________________________________               ________________________________________

                                                  FAMILY HISTORY

1.    Father’s Health _______________________________________________________________________

      Died of ___________________________         Age at death _________ years old

2.    Mother’s Health________________________________________________________________________

      Died of ___________________________         Age at death _________ years old

3.    Does any other member of your family have other medical problems? Please list.

      Relative ___________________________ Problems ________________________________________
      Relative ___________________________ Problems ________________________________________
      Relative ___________________________ Problems ________________________________________
      Relative ___________________________ Problems ________________________________________

4.    Does any other member of your family have sleep apnea or other sleep problems? Please explain.

      Relative ___________________________ Sleep Problems ___________________________________
      Relative ___________________________ Sleep Problems ___________________________________
      Relative ___________________________ Sleep Problems ___________________________________

                                    DOB:                                Place Patient                         PAGE 7 OF 9
                                    FIN:                                 Label Here
                                             Epworth Sleepiness Scale
Name: ________________________________________________                        Today’s Date: ___________________
How likely are you to doze off or fall asleep in the following situations, in contrast to feeling just tired? This refers to
your usual way of life in recent times. Even if you have not done some of these things recently try to work out how
they would have affected you.

                 Use the following scale to choose the most appropriate number for each situation below:
                  0 = would never doze                      1 = slight chance of dozing
                  2 = moderate chance of dozing             3 = high chance of dozing

                                     Make sure you circle a number for each situation.

           SITUATION                                                                   CHANCE OF DOZING
      1.   Sitting and Reading                                                            0 1 2 3
      2.   Watching Television                                                            0 1 2 3
      3.   Sitting inactive in a public place (e.g., a theater or meeting)                0 1 2 3
      4.   As a passenger in a car for an hour without a break                            0 1 2 3
      5.   Lying down to rest in the afternoon when circumstances permit                  0 1 2 3
      6.   Sitting and talking to someone                                                 0 1 2 3
      7.   Sitting quietly after lunch without alcohol                                    0 1 2 3
      8.   In a car, while stopped in traffic                                             0 1 2 3
                                                                                      TOTAL SCORE: ______
                                                                                 (Maximum = 24. Normal < 10)

                                               Fatigue Severity Scale
This questionnaire contains nine statements that rate the severity of your fatigue symptoms. Read each statement and
circle a number from 1 to 7, based on how accurately it reflects your condition during the past week and the extent to
which you agree or disagree that the statement applies to you. A low number indicates strong disagreement with the
statement, whereas a high value indicates a strong agreement with the statement.

                                    Make sure you circle a number for every statement.

                During the past week, I have found that:                             Disagree-------------Agree
                                                                                     very much             very much
           1.   My motivation is lower when I am fatigued                           1 2 3 4 5 6 7
           2.   Exercise brings on my fatigue                                       1 2 3 4 5 6 7
           3.   I am easily fatigued                                                1 2 3 4 5 6 7
           4.   Fatigue interferes with my physical functioning                     1 2 3 4 5 6 7
           5.   Fatigue causes frequent problems for me                             1 2 3 4 5 6 7
           6.   My fatigue prevents sustained physical functioning                  1 2 3 4 5 6 7
           7.   Fatigue interferes with carrying out certain responsibilities       1 2 3 4 5 6 7
           8.   Fatigue is among my three most disabling symptoms                   1 2 3 4 5 6 7
           9.   Fatigue interferes with my work, family, or social life             1 2 3 4 5 6 7
                                                                                   TOTAL SCORE: ______
                                                                              (Maximum = 63. Normal < 36)

                                      DOB:                                Place Patient                         PAGE 8 OF 9
                                      FIN:                                 Label Here
                                           Review of Systems
          CONSTITUTIONAL SYMPTOMS                                           NEUROLOGICAL
 Good general health                 No     Yes         Morning headaches                      No     Yes
 Recent weight loss                  No     Yes         Migraine headaches                     No     Yes
 Recent weight gain                  No     Yes         Dizziness                              No     Yes
 Fevers                              No     Yes         Seizures                               No     Yes
 Night sweats                        No     Yes         Tremors                                No     Yes
 Excessive sleepiness                No     Yes         Paralysis/ weakness (extremities)      No     Yes
 Fatigue/ Tiredness                  No     Yes         Numbness/ tingling (hands and feet)    No     Yes
 Snoring during sleep                No     Yes
                      EYES                               Joint pains                           No    Yes
Double vision                        No     Yes          Joint stiffness                       No    Yes
Blurred vision                       No     Yes          Joint swelling                        No    Yes
Suffer from Glaucoma                 No     Yes          Back pains                            No    Yes
                                                         Muscle cramps or pains                No    Yes
       EAR, NOSE, THROAT AND MOUTH                       Difficulty walking                    No    Yes

Ringing in the ears                   No    Yes                             GENITOURINARY
Difficulty hearing                    No    Yes
Earaches                              No    Yes          Frequent urination                    No     Yes
Chronic sinus drainage                No    Yes          Burning urination                     No     Yes
Chronic sinus congestion              No    Yes          Urinary Incontinence                  No     Yes
Frequent sneezing                     No    Yes          Blood in urine                        No     Yes
Mouth sores                           No    Yes          Sexual problems                       No     Yes
Bleeding gums                         No    Yes          Testicular pain (Males)               No     Yes
Bad breath                            No    Yes          Vaginal discharge (Females)           No     Yes
Swollen glands in neck                No    Yes
Change in voice (hoarseness)          No    Yes
                                                                INTEGUMENTARY (SKIN / BREAST)
                                                         Itching or Rash                       No     Yes
                  PULMONARY                              Varicose veins                        No     Yes
                                                         Change in skin color                  No     Yes
Chronic cough                         No    Yes
                                                         Abnormality in nails/ hair            No     Yes
Shortness of breath                   No    Yes
                                                         Breast pain                           No     Yes
Wheezing                              No    Yes
                                                         Breast lump                           No     Yes
Blood in sputum                       No    Yes
                                                         Nipple discharge                      No     Yes
Pain with breathing                   No    Yes
                                                         Depression                            No     Yes
Chest pains                           No    Yes          Mood swings                           No     Yes
Palpitations (heart racing)           No    Yes          Increased irritability                No     Yes
Swelling of the feet                  No    Yes          Difficulty concentrating              No     Yes
Shortness of breath on exertion       No    Yes          Memory loss/ confusion                No     Yes
                                                         Nervousness/ anxiety                  No     Yes
              GASTROINTESTINAL                           Difficulty sleeping                   No     Yes
Heartburn                             No    Yes
Nausea or vomiting                    No    Yes                              ENDOCRINE
Poor appetite                         No    Yes          Excessive thirst                     No     Yes
Change in bowel movements             No    Yes          Poor control of blood sugar          No     Yes
Diarrhea                              No    Yes          Intolerance to heat                  No     Yes
Constipation                          No    Yes          Intolerance to cold                  No     Yes
Blood in stool                        No    Yes          Dry skin                             No     Yes
Black, tarry stools                   No    Yes          Change in hat or glove size          No     Yes

         HEMATOLOGICAL/ LYMPHATIC                                   ALLERGIC / IMMUNOLOGIC
Easy bruising                        No     Yes           Nasal allergies/ Hayfever           No     Yes
Excessive bleeding                   No     Yes           Recurrent hives                     No     Yes
Enlarged glands/ lymph nodes         No     Yes           Allergy to foods                    No     Yes

                                  DOB:                      Place Patient                           PAGE 9 OF 9
                                  FIN:                       Label Here

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