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What should be included in the profile of a patient?
Patient profile should have all the facts. The more facts that are available about a patient, the better diagnosis and treatment are possible. Where is your profile from your 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. This is how you need to elaborate your profile. Address Activities of everyday living Annual health assessment Assets Abilities/skills Allergies Complaint/problem Communications Duties Detention Education Habits Hospitalization Impairment Rating and Disability Determination Language Last updated Photograph Profession Referrals Survival Needs Stress Surgical History 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? _________________________ What years did you go to high school? _________________________ What years did you go to college? _________________________ 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? _________________________ Allergies Are you allergic to anything (medications, foods, latex)? _________________________ (Yes / No) If yes, please list: _________________________ 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? _________________________ _________________________ _________________________ _________________________ _________________________ Do you have any other problems? _________________________ Can you explain? _________________________ Communications What is the best method to communicate with you? E-mail. Fax. Telephone call. Postal mail. Communication through media. _________________________ Habits Do you smoke now? (Yes / No) How much? __________________ Have you ever smoked? (Yes / No) If yes, for how many years? ________ When did you quit? _______________ Do you drink alcohol? (Yes / No) If yes, how much? __________________ How often? ___________________ Have you used recreational drugs? (Yes / No) If yes, which ones? _______________________________________________ When was the last time you used one/them? ___________________________ Impairment Rating and Disability Determination Health status How would you describe your health status relevant to your age? _________________________ 100% mentally fit. 100% physically fit. Do you have any problems with activities mentioned below relevant to your age? Walking Seeing Hearing Speaking Breathing Learning Working Caring for oneself (eating, dressing, toileting, etc.) Performing manual tasks Getting started after sleep Sitting Sleeping _________________________ Last updated When was the record first created? _________________________ When was the record last updated? _________________________ Who created the record? _________________________ Who updates the record? _________________________ When were you last seen by a medical doctor? _________________________ What is the profile and contact information of the medical doctor? _________________________ Surgical History Have you ever undergone surgery? _________________________ (Yes / No) If yes, please list operations and dates: _________________________ These are basic questions. There are many more. Here are further guidelines. |