; NORTH SHORE!
Documents
Resources
Learning Center
Upload
Plans & pricing Sign in
Sign Out
Your Federal Quarterly Tax Payments are due April 15th Get Help Now >>

NORTH SHORE!

VIEWS: 5 PAGES: 2

NORTH SHORE!

More Info
  • pg 1
									NORTH SHORE
Last Name:
First Name:
PRIVATE HOSPITAL
Date of Birth:
PATIENT HEALTH QUESTIONNAIRE
Please answer questions by ticking the appropriate box. Provide details in the right hand column.
Medications
□ No I] Yes >
Do you take anti-inflammatory drugs or cortisone?
Do you take blood thinners such as warfarin, asprin.
Plavix or Iscover?
U No DYcs > T yes. please list under "Name of Medication" below.
	If you need more space add a separate sheet of paper
Do you take any other medications such as tablets,
pills, injections, puffers, eye drops, creams?
_ No _ J Yes >
Name of Medication
Dose
How often
73
>
H
m
Z
Do you have any allergies?
(Especially to medications, food, sticking plaster)
How tall are you?
□ No DYes >
H
X
cm/ins
How much to you weigh?
Kg/lbs
m
Operations
>
r"
LJ No LJYes > If yes. please list below
Have you had any previous operations?
-I
X
Operations
Year
Comments
o
c
m
i/i
H
0
z
z
Have you or any of your blood relatives had any
reactions to anaesthetic, including at the dentist?
Do you have any other conditions that may require
further explanations?
>
□ No DYes >
73
□ No DYes >
m
Do you have - or have you ever had any of the following conditions
□ No DYes >
High blood pressure
□ No U Yes > How often
Chest pain or angina
□ No DYes > When
Heart attack or coronary
Any other heart condition
□ No DYes > What type
LJ No _JYes > Treatment e.g. CPAP
Sleep apnoea
Troublesome shortness of breath after
□ No DYes >
a) Walking more than 50 metres
□ No _ Yes >
[J No LJYes >
b) Climbing stairs or inclines
□ No DYes >
c) sleeping flat at night
□ No DYes >
Chronic bronchitis, cough or sputum
□ No DYes > How often
Asthma
i^-
□ No DYes
o
Diet controlled
Z
Diabetes
! ! No . Yes > Do you take diabetic tablets . ! No Yes
□ No DYes
D
Q.
Do you use insulin
Please Turn Over
Z
MROIa
Continued - Do you have - or have you ever had any of the following conditions
□ No DYes > When was the last one
Epilepsy or fits
□ No DYes > When
Stroke
□ No DYes > When
Black outs or fitting
□ No DYes > What type
Blood clots or bleeding disorder
□ No DYes > What type
Anaemia
□ No DYes > When
Previous blood transfusion
□ No DYes > What type
Kidney condition
□ No DYes > What type
Hepatitis or liver condition
□ No □Yes> Wh,tWe'
Arthritis
Where, specific
Is there a condition that runs in the family
(e.g. - haemophilia, muscular dystrophy)
□ No DYes >
D No ! Yes > How much. How long
Do you or have you ever smoked
□ No DYes > How much per week
Do you drink alcohol
Discharge Planning
Do you live alone
C No . lYes >
No J Yes >
I have someone to look after me after discharge
Are you solely responsible for the care of another
person at home?	
□ No DYes >
Do you currently receive community support services? No ! Yes >
Do you require assistance with any aspect of the day
to day living?	
□ No DYes >
Where do you plan to go after discharge?
How will you get there
No DYes > Where
Will you require rehabiliation on discharge
Nurse Use Only
Name of Admitting Nurse:
Designation:
Signature:
Time:
Date:
Comments (office use)
TRIAL FORM
MROIa

								
To top