What is your name?
____________________________________
What is your mailing address?
____________________________________
How long have you lived here?
____________________________________
What is the date of birth?
____________________________________
How old are you?
____________________________________
What is the gender?
____________________________________
What is its e-mail, fax, telephone, and mailing address?
____________________________________
What was the mailing address of the patient from birth until now?
____________________________________
What is your height?
____________________________________
What is your weight?
____________________________________
What is the color of your skin?
____________________________________
What is the color of your hair?
____________________________________
How many brothers and sisters do you have?
____________________________________
What best describes your problem?
Annual health assessment.
The new problem is not a medical emergency.
Follow-up medical consultation.
Problem that is a medical emergency (In case of a medical emergency, your local emergency service is the first responder. Guidelines for your local emergency responder are at this location: http:www.qureshiuniversity.com/emergencyworld.html).
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 your diagnosis and treatment as of November 29, 2011?
____________________________________
What is the name and contact information of the medical doctor who gave you this diagnosis and treatment?
____________________________________
Did you have any problem as of November 28, 2011?
____________________________________
How are you feeling today?
____________________________________
Do you have any problems today?
____________________________________
What is your normal day like?
____________________________________
Where do you go for medical diagnosis and treatment?
____________________________________
Are your medical needs being met by your current provider?
____________________________________
Do you have transportation needs?
____________________________________
Are you interested in learning about physical fitness?
____________________________________
Are you interested in learning about nutrition?
____________________________________
Are you interested in learning about healthful cooking?
____________________________________
What are you general health concerns?
____________________________________
What are my goals?
____________________________________
Do you have diabetes?
____________________________________
What seems to be the problem?
Do you feel this is a new medical problem?
On what date are you writing this document?
Where is the patient on the date you are writing this document?
Where is he at this point as of March 10, 2011?
Who is writing this document?
Patient
Relative
Secretary
Referring medical doctor
Social service
Police
Court
If other, please specify
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Patient Profile and History
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Social History
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Are you on a special diet?
Do you have any chronic condition like hypertension, diabetes, asthma, etc.?
What was the indication of medication?
Were you ever hospitalized?
What was the indication?
How do you commute?
Do you need any assistance?
Why do you need assistance?
What is your eyesight number?
Who gave you this eyesight number?
How did they calculate this number?
Did you ever have any surgery?
When and where did you have the surgery?
What was the procedure?
Where are the surgical notes?
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Chief Complaint(s)
What is the main reason for your visit today?
How long does the problem last?
Is anything else occurring at the same time?
Yes__ No__ If yes, please explain.
Nausea__ Rash__ Headache__ Other__
Is the problem constant or variable?
When did you first notice the problem?
2 days ago__ 2 weeks ago__ 1 month ago__ Other__
Does anything help or make the problem worse?
Moving around__ Standing__ up Lying on side__ Other__
Does the problem interfere with your normal functions?
Are you on any medications?
Are you on a special diet?
Do you have any chronic condition like hypertension, diabetes, asthma, etc.?
Were you ever on any medication for more than one week?
What was the indication of medication?
Were you ever hospitalized?
What was the indication?
How do you commute?
Do you need any assistance?
Why do you need assistance?
What is your eyesight number?
Who gave you this eyesight number?
How did they calculate this number?
Did you ever have any surgery?
When and where did you have the surgery?
What was the procedure?
Where are the surgical notes?
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Present Illness |
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Personal Health History |
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Allergy
Does the patient have any known medical allergies?
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What are the relevant questions you need to ask?
Do you have any problem as of today?
Is there any issue that you think is a problem?
Have I seen you face to face?
What do you look like?
Can you forward a recent photograph?
When and where was the photograph taken?
My goals are that a person should live up to at least 90 years without any disability.
Who from your family or relatives should be contacted in case of an emergency?
Habits |
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Immunization history |
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Growth chart and developmental history |
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Medical encounters |
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Physical examination |
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Assessment and plan(diagnosis, treatment, etc.). |
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Orders and prescriptions |
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Progress notes |
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Test results |
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Other information |
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Administrative issues |
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Demographics |
http://www.qureshiuniversity.com/hrmanagement.html
http://www.qureshiuniversity.com/hrmanagement.txt
Work-specific
Do you prefer working alone or in a team?
What is the role you adopt whilst working in a team?
Tell me about a problem you faced whilst working in a team. How did you resolve the problem?
How good are you at solving conflicts?
What was the biggest challenge you ever faced?
Which areas of the world would you like to explore and why?
Are you good at handling several tasks and responsibilities simultaneously?
Tell me a joke.
How do you determine priorities in your planning?
How would your friends describe you?
What would you like to improve professionally about yourself?
How many airplanes are there in the world?
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