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Address Activities of everyday living Annual health assessment Assets Abilities/skills Complaint/problem Communications Duties Detention Education Hospitalization Language Photograph Profession Referrals Survival Needs Stress Travel history What is your name? _________________________ What is your date of birth? _________________________ Where and when were you born? _________________________ What is your gender? _________________________ Address What is your mailing address? ________________________ ________________________ ________________________ ________________________ Where are you located now? ________________________ What was your mailing address from birth until now? _________________________ _________________________ _________________________ _________________________ Where do you live now? _________________________ How long have you lived at this address? _________________________ What is your contact information including current mailing address, telephone, e-mail, and any other details, and person to contact in case of emergency? _________________________ _________________________ _________________________ _________________________ _________________________ _________________________ How long do you plan to live at this address? _________________________ Activities of everyday living What is your normal day like? _________________________ What do you normally enjoy doing? _________________________ Annual health assessment When was your last annual health assessment done? _________________________ Who did your last annual health assessment? _________________________ What were the findings? _________________________ What were the recommendations? _________________________ Did the recommendations help? _________________________ Was it an annual health assessment or evaluation of a new problem? _________________________ When did you last see a medical doctor? _________________________ Did you see a medical doctor for an annual health assessment or a new problem? _________________________ What seemed to be the problem? _________________________ What was the diagnosis and treatment? _________________________ What is the name and contact information of the medical doctor who gave you this diagnosis and treatment? _________________________ Assets What are your assets? _________________________ Abilities/skills What are your abilities and skills? _________________________ Complaint/problem Do you have any complaint/problem relevant to human health care today? _________________________ If you have any complaint/problem relevant to human health care today, what are the details? _________________________ How are you feeling today? _________________________ Do you have any problems today? _________________________ What seems to be the problem? _________________________ _________________________ _________________________ _________________________ _________________________ Communications What is the best method to communicate with you? E-mail. Fax. Telephone call. Postal mail. Communication through media. _________________________ Duties Do you have any duties? _________________________ Who assigned you these duties? _________________________ Detention Were you ever detained or jailed? _________________________ How many times and how long were you detained or jailed, and what were the reasons? _________________________ Do you think your detention and/or being put in jail was justified? _________________________ What concept of law is applicable to this scenario? _________________________ Education How would you rank your education level? _________________________ Is you educational level at primary school, middle school, high school, associate’s degree, bachelor’s, master’s, or doctoral degree? _________________________ What subjects have you studied? _________________________ What profession have you studied? _________________________ What are your abilities? _________________________ What services can you provide? _________________________ Have you designed or developed any products and services? _________________________ What are the issues? _________________________ Did your parents/guardians and school raise you with liberal values, religious values, or some other values? _________________________ How were you raised? _________________________ What best describes your English language abilities? _________________________ What details should I know about you now that might later create problems for me, you, and others? _________________________ What are your goals or plans? _________________________ Hospitalization When was the last time you were hospitalized? _________________________ What were the reasons for hospitalization? _________________________ How long did the hospitalization last? _________________________ Do you think the hospitalization was justified? _________________________ Language Do you understand, speak, read, and write the English language? _________________________ What languages can you understand, speak, read, and write? _________________________ Photograph Where is your recent photograph? _________________________ Where and when was this photograph taken? _________________________ Where is your state ID with a photograph? _________________________ Profession What profession do you identify with? _________________________ Referrals Did anyone refer you to this resource? _________________________ Did the referring resource provide any referring document? _________________________ Who referred you? _________________________ What are the details of referral? _________________________ Survival Needs Has the state provided you enough survival needs? _________________________ Stress Do you feel stressed now? _________________________ What are normal complaints, symptoms, and signs of stress? _________________________ Do you have any of the complaints, symptoms, and signs of stress listed? _________________________ What do you think is the cause of your stress? _________________________ What do you know about stress? _________________________ Write down any symptoms you're having, including any that may seem unrelated to the reason for which you scheduled the consultation. Note when your symptoms bother you most — for example, if your symptoms tend to get worse at certain times of the day, during certain seasons, or when you're exposed to cold air, pollen or other triggers. _________________________ _________________________ _________________________ Write down key personal information, including any major stresses or recent life changes. _________________________ _________________________ Make a list of all medications, vitamins and supplements that you're taking.Take a family member or friend along, if possible. Sometimes it can be difficult to recall all the information provided to you during an appointment. Someone who accompanies you may remember something that you missed or forgot. _________________________ Write down questions to ask your doctor. _________________________ 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. Where is the patient now? _________________________ Travel history Where have you travelled up to now in North America, Asia, Africa, Australia, Latin America, or Islands even for one day? _________________________ These are basic questions. There are many more. |