How should you elaborate your profile?
What should I know about you? Patient Profile

New Patient Consultation
http://www.qureshiuniversity.com/medicalhistory.html

Medical emergency
http://www.qureshiuniversity.com/medicalemergency.html

First Name: ---------
Last Name:
Favourite Name(Nickname):---------

Age:	-
Address:	Mailing Address: - City: State: Zip: Telephone: Email Address: Location of Residence:
Activities of everyday living:	Sedintry life/Active Life
Anthropometric measurements:	Height: 169 cms 5.5 feet Weight: 54 kgs 118.8 lbs Eye Color: Brown Hair Color: Black Body mass index
Annual health assessment:	On November 8, 2012 annual health assessment was done.
Annual Physical Examinations:
Abilities/skills(Talents):
Address from birth until now:
Assets:
Additional Information:	(Elaborate on any section of this Individual's Profile)
Allergies:
Appointment Scheduling Instructions:
Scheduling an appointment Canceling an existing appointment Modify an existing appointment Next Appointment Date Time Click on the box for appointment types and select the appropriate option: a. Routine Labs b. Drug Screen c. Glucose Tolerance Test (GTT) d. Pediatric Draw
Birthplace:
Contact Information:
Complaint or issue type:
Chief Complaint:
Children: No
Complaint/reason for consultation:	Cough on November 8, 2012.
Children:	Yes
Current Medications schedule:
Current diet:
Current treatments:
Date of Birth:	-
Date of last yearly assessment/physical exam:
Date of last blood tests:
Diagnosis:	_________
Duties, if any:
Date of last physical/annual exam:
Date of last blood tests:
Emergency issues, if any:
Emergency Contact Name:	Emergency Contact Name: Phone: Email Address: Relationship:
Educational level:
English Ability:	None, Basic, Intermediate, Advanced
Emergency Contact Name:	Phone: Email Address: Relationship:
Emergency:
Emergency medical record:
Emergency Department record:
Education:
Family/relationship:
Food likes/dislikes:
Fun and relaxation interests:
Follow-up medical consultation:	November 9, 2012 (Cancelled)Advised oral medication instead of injection verbally Next consultation November 17, 2012
Family History:
Family structure or size:
Friends:
Food:
Final Diagnosis:
Gender:
Goals/dreams/plans:
Geographic Preferences:
General Physical Status:	Walks: Stairs: Help Needed with Mobility: Bed: Wheelchair: Transfers: Fall Risk: Vision: Fracture Risk:
Health Calculators:
Habits:	Drinking: No Smoking: No
Hospitalization records:	Date and Time of Admission:
Health Status:	Health Issues (Describe limitations in daily activity, minimum required care by nurse or physician, frequency of ______, etc):
Immunization Record:	Tetanus Pneumonia Vaccine Flu Vaccine Hepatitis B Vaccine Other
ID:
Identity Card:
Internet health care resource for the resident:
Language:
Location of Residence:
Last updated:	November 8, 2012 Completed By: Date Completed: Title:
Living situation:
Law applicable to specific scenarios:
Location of individual at this point:
Languages abilities:
Likes/dislikes:	What I don't like: Spiritual wants/interests: Other significant interests/preferences: The important people in my life are: My dreams for the future are: What most people like about me best: What I like best about others: My gifts and talents are:
Medical history:	Present history
Medical Record:
Medical record correction:
Medical doctor to medical doctor communication about patient:
Mental status examination:	Normal
Medications:	Current Medications:Inhaler, Oral steriods(November 10, 2012) Dosage: Reason for Taking: Directions: Doctor:Naveed(DM) Date Started:
Medical emergency resource for the resident:
Major Achievements:
Name and contact information:	First Name: Last Name: Nickname: Contact Information: Telephone: Your Email Address:
Normal day:
Other Languages:	-
Outpatient medical services record:
Problem/Complaint:
Personal Profile:	Key Skills: Communication Teamwork Leadership Initiative Interpersonal skills Numeracy Planning & organising Problem solving Flexibility Enthusiasm. General skills: Technical skills: Management skills: Language skills: Other languages skills:
Photograph:	-
Primary Language Understood:
Primary Means of Expression:
Profession:
Primary health care physician for the resident:
Physical fitness:
Past History:
Personality questions:
Physical examination:
Vitals: Consciousness is extremely essential in reaching a correct diagnosis and treatment. Consciousness, pulse, blood pressure, respiratory rate, temperature. Review of systems
Primary Care Physician Name, Address and Phone:
Profession:
Products or services abilities:
Primary Care Physician Name, Address and Phone:
Publications:
Protective devices/medical equipment: (If Other)
Race:
Relationship status:
Referred by:
Relatives:
Relationships:
Religion/spirituality/beliefs:	Muslim
Referred by:	Mailing Address:
Remarks:
State and outside state travel:
Self Help Skills Status:	Eating: Dressing: Bathing: Toothbrushing: Toileting: Medication Administration:
Services and Supports Needed:
Signs/Symptoms:
Social Interests:
Surgical history:
Special needs:
State ID Card:
Tests:
Travel history:
Treatment:
Work interests:

Medical Record

What goals do you have for your consultation today? Primary Care OB/Gyn Other www.qureshiuniversity.com/medicalrecordnewpatient.html What are the sources of medical history? Patient. Family. Patient not responding to medical history questions. Community member. Police officer. Referral from medical doctor. Other.