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Profile from birth until now If your profile is available, you do not need to answer these questions. If your profile is not maintained with me, you need to answer these questions. If you have difficulty elaborating your profile, you can be helped with sample examples. | |||||||
| Annual health assessment of a child | |||||||
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Yearly health assessment Annual health assessment What are the details of the problems or complaints you had in past one year? _________________________ What are the details of the problems or complaints you think you will face in the years ahead? _________________________ Do you have enough survival needs? _________________________ What are details of your survival needs for next year? _________________________ 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? _________________________ How are you feeling today? _________________________ Do you have any problems today? _________________________ What seems to be the problem? _________________________ _________________________ _________________________ _________________________ _________________________ Did you know that 90% of doctor visits are for stress related symptoms? _________________________ What do you know about stress? _________________________ 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? _________________________ Where do you live now? _________________________ What is your telephone number? _________________________ What is your e-mail address or fax number? _________________________ Who has your medical record? _________________________ Can I get a copy of your medical record? _________________________ If you do not have a medical record and need to be my patient, a new medical record needs to be created. This will take a few weeks. You need to forward details about yourself. This will be followed by various specific questions. What best describes your problem? _________________________ What is the reason for consultation? _________________________
There are many more. One copy of your yearly health assessment goes to the state department of health. One copy of your yearly health assessment remains with your primary care physician. |
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Referred by:_________________________ How long have you known the patient? ______________________________________ What are the details of the primary health care physician of a resident/patient? Primary Care Physician Name, Address and Phone:__________________ _______________________ _______________________ _______________________ _______________________ Here are helpful guidelines to describe your primary physician. I do not have a primary health care physician. My primary health care physician is not able to answer relevant questions via e-mail, fax, phone, postal mail, or face-to-face. There are no competent primary care physicians in the area I am living. I need a primary health care physician able to reach a correct diagnosis and treat me in various health care settings, and able to answer relevant questions via e-mail, fax, postal mail, and face-to-face. |
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Emergency Contact Name:______________ Phone: _______________________ Email Address: _______________________ Relationship:________________________ |
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What is included in a yearly health assessment? |
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What are findings about other medical doctors and health care providers? Most of the medical doctors claiming to be highly specialized health care providers up to March 30, 2013 did not provide this type of yearly health assessment. All medical doctors and health care providers are required to provide this type of quality yearly health assessment. They should not call themselves specialists without at least quality yearly health assessment. What type of health care screening is usually done but is not helpful and sometimes is harmful due to wrong results/false positives? Cancer screening, PPD test, Elisa tests, etc. Is this type of health care screening useful? No. 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. _________________________ |
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Annual Physical Exam: The Basics Date of Examination:_________________________ Physician Name:_________________________ Physician Address:_________________________ |
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(For women only) Are you pregnant or breast feeding? _____________________ Date of your last menstrual period: ______________________ How many children do you have? ______________________ How were they delivered? ______________________ Human Vital Signs 1. Consciousness:_________________________ 2. Pulse rate:_________________________ 3. Blood pressure:_________________________ 4. Respiration rate:_________________________ 5. Body temperature:_________________________ 6. Emotion:_________________________ Vital Signs. These are some vital signs checked by your doctor: Blood pressure: less than 120 over 80 is a normal blood pressure. Doctors define high blood pressure (hypertension) as 140 over 90 or higher. Heart rate: Values between 60 and 100 are considered normal. Many healthy people have heart rates slower than 60, however. Respiration rate: Around 16 is normal. Breathing more than 20 times per minute can suggest heart or lung problems. Temperature: 98.6 degrees Fahrenheit is the average, but healthy people can have resting temperatures slightly higher or lower. Vision & Hearing Screening Height:_________________________ Weight:_________________________ Waist, hip circumferences:_________________________ BMI:_________________________
< 20 BMI Low body weight 20 to 25 BMI Healthy weight for most people >25 to 27 BMI Weight may lead to health problems 27 to 29 BMI Overweight. Associated with increase in morbidity and mortality. > 30 BMI Obese Ears/Nose:_________________________ Oral Cavity:_________________________ Endocrine:_________________________ Lymph Nodes:_________________________ Lungs:_________________________ Heart:_________________________ Breasts:_________________________ Abdomen:_________________________ Genitals:_________________________ Female Physical Exam:_________________________ Male Physical Exam:_________________________ Extremities / Musculoskeletal:_________________________ Habitus:_________________________ Skin:_________________________ Psychiatric:_________________________ Neurologic:_________________________ Laboratory Tests Complete blood count Chemistry panel Urinalysis (UA) Prescription |