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Practice Checklist Before the visit: Explain the Comprehensive Health Assessment Visit to the patient Is the problem list complete? Is the medication list complete (Prescription and over-the-counter medicine)? Is the family history complete (Medical and surgical)? Do we have a list of the patient’s other physicians? Are most recent laboratory findings, radiographic findings and EKG screenings in the record? Did the patient receive a reminder for the visit? During the visit: Have the patient complete a depression screen (Adult and adolescents using PHQ2, PHQ9 or other ______ recognized tool) Update patient demographics (Age, gender, and phone number), allergies, patient’s chief complaint and history of present illness. Measure BP, weight, height and/or waist measurement Complete review of risk factors and mental health status (Behaviors affecting health, medical history of patient and family, patient and family mental health/substance abuse) Address communication needs taking into consideration family/social/cultural characteristics Update immunization record and order immunizations. Update preventive and chronic conditions screenings. (Includes developmental screening using a standardized tool for pediatric patients) Provider review and documentation of medical conditions: -- Diabetes, HTN, CAD/MI, HF, COPD, Asthma, Cancer, IBS -- Medical condition status (Active/Stable, progressive, resolved) -- Review and reconcile medications. Provider review and documentation of Plan of Care. Address important condition specific gaps in care: -- Medication and treatment history: poly-pharmacy, multiple providers, reason for hospitalization (if applicable), reason for ER visit (if applicable) -- Weight loss/gain in last 6 months -- Appetite change -- Sleep changes -- Chronic pain status Discuss advance directive. (NA for pediatrics) Refer for: [ ] Screening tests [ ] Nutritional interventions [ ] Treatment of depression [ ] Self-Management Support (Community referral, Case Management Programs) [ ] Tobacco cessation [ ] Behavioral Health/Social Worker Comprehensive medical history and physical exam. Comprehensive lab assessments. Diagnostic tests as part of this include: Urinalysis -- To detect kidney disease, prostate problems, and infection ABC with differential -- To detect anemia, blood diseases, and infection OP-16 chemistry -- Complete chemistry panel to detect kidney disease, diabetes, and liver disease Lipid panel -- Complete profile of blood cholesterol levels Thyroid stimulating hormone -- To detect an under- or overactive thyroid C-reactive protein -- To detect an inflammatory marker that may signify risk for coronary artery disease Prostate-specific antigen (PSA) -- To detect prostate cancer or prostate enlargement. For males over the age of 40 Chest x-ray -- To screen for lung cancer, infection, and other lung diseases EKG -- To screen for a number of potential problems, including irregular heart rhythms, damage to the heart muscle, enlargement of the heart's chambers, mineral imbalances in the blood, and detection of a heart attack Exercise Tolerance Test (ETT) Body Fat Assessment Nutrition Review Fitness Consultation Stress Management Evaluation Five Year Risk Asessment for Heart Disease, Stroke and Diabetes Comprehensive Geriatric Assessment |
| In the past, have you been diagnosed as having any of the following conditions? |
Allergic rhinitis Angina Arthritis Asthma Any kind of Cancer Bulimia or Anorexia Cataracts Cervical (neck) strain Chronic bronchitis Cluster headaches Congestive heart failure Chronic Fatigue syndrome Chronic Fatigue syndrome Chronic Fatigue syndrome Diverticulitis Diverticulosis Depression Diabetes Dysmenorrhea Emphysema Enlarged prostate Epididymitis Fibrocystic breast disease Fibromyalgia Gallstones Galactorrhea(breast discharge) Gastritis/Esophagitis Giardia or other parasite Glaucoma Gum disease Hardening of the arteries Heart attack Heart Murmur Hemorrhoid Hepatitis A, B or C High cholesterol or Triglycerides Hypoglycemia High blood pressure Hyperthyroidism (over-active thyroid) Hypothyroidism (low thyroid) Irritable bowel (spastic colon) Iron deficiency anemia Kidney Stone Lupus Lymphoma Malabsorption Menieres Disease Migraine headaches Multiple sclerosis Neurologic disease Nasal polyps Panic attacks Pelvic inflammatory disease PMS or PMDD Prostatitis (prostate infection) Pyelonephritis (kidney infection) Peptic ulcer (gastric or duodenal) Pernicious anemia Phlebitis Pneumonia Rheumatoid arthritis Reflux or GERD Sexual dysfunction Sinusitis Stroke or "TIA" Tension headaches Tonsillitis Ulcerative colitis Uterine Fibroids Vaginitis |
| Presently or in the recent past, have you had any of the following symptoms: |
Abdominal burning pain Abdominal cramping pain Blood in or on stool Blood in urine Breast lump Breast Pain Change in appetite Change in bowel habits Change in hearing Change in menstrual periods Change in sexual desire Change in urinary habits Change in vision Changes in hair Changes in skin or moles Chest pressure of tightness at rest Chest pressure or tightness on exertion Chills Chronic cough Constant sinus drainage Constipation Coughing up blood Coughing up phlegm in the morning Depression Diarrhea Double vision Easy bruising or bleeding Feeling dizzy or off-balance Feeling faint or almost passing out Fever Frequent nosebleeds Frequent or urgent urination Generalized body aches Generalized fatigue Generalized weaknes Head injury and loss of consciousness Heartburn or indigestion Hoarseness Joint pains Joint swelling Lumps in neck, underarms or groin Memory loss Mood swings Muscle weakness or pain Nausea Neck stiffness Nervousness, panic Night Sweats Nipple discharge Numbness Pain in legs while walking Painful urination Rectal bleeding Recurrent gum or tooth infections Recurrent headaches Recurrent sinus infection Recurrent sore throats Ringing in ears Seizures or convulsions Sensation of being too hot or too cold Shortness of breath on exertion Shortness of breath while laying down Skin rash Swollen ankles or feet Swollen glands Testicular pain Testicular swelling Tingling in hands or feet Trouble sleeping Trouble swallowing aginal discharge or odor Vomiting Weight gain Weight loss |
| How stressed are you? |
Stress Warning Signs and Symptoms
Cognitive Symptoms Memory problems Inability to concentrate Poor judgment Seeing only the negative Anxious or racing thoughts Constant worrying Emotional Symptoms Moodiness Irritability or short temper Agitation, inability to relax Feeling overwhelmed Sense of loneliness and isolation Depression or general unhappiness Physical Symptoms Aches and pains Diarrhea or constipation Nausea, dizziness Chest pain, rapid heartbeat Loss of sex drive Frequent colds Behavioral Symptoms Eating more or less Sleeping too much or too little Isolating yourself from others Procrastinating or neglecting responsibilities Using alcohol, cigarettes, or drugs to relax Nervous habits (e.g. nail biting, pacing) |
| Medical Specialty | |
| Cardiology | |
| Dermatology | |
| Disability Specialist | |
| Emergency Medicine | |
| Endocrinology | |
| Forensic Medicine International | |
| Gastroenterology | |
| Geriatrics | |
| Hematology | |
| Internet Healthcare | |
| Internal Medicine | |
| Medical Negligence (Medical Malpractice Specialist) | |
| Microbiology | |
| Nephrology | |
| Neurology | |
| Oncology | |
| Ophthalmology | |
| Orthopedics | |
| Otorhinolaryngology | |
| Obstetrics & Gynecology | |
Primary care physician (Family & General Practice)
| |
| Pediatrics | |
| Psychiatry | |
| Pulmonary Medicine | |
| Physical Medicine & Rehabilitation | |
| Public Health/Social and Preventive Medicine | |
| Radiology & Nuclear Medicine | |
| Surgery |