Patient Initial Visit Data Essay

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OFFICE EVALUATION WORKSHEET NAME____________________________________AGE____________________DOB_________ DATE______________________________REFERRING MD_____________________________ SMOKING HISTORY_________PPD_________YEARS CHIEF COMPLAINT and DURATION PREVIOUS MEDICATIONS USED and RESPONSE COUGH SPUTUM DYSPNEA CHEST PAIN HOARSENESS HEMOPTYSIS WHEEZE COLD AIR, FUME OR SMOKE ASSOCIATED SYMPTOMS WEIGHT LOSS OR ANOREXIA NIGHT SWEATS, FEVER, CHILLS PND, ORTHOPNEA OR ANKLE EDEMA PATIENT INITIAL VISIT DATA Date Name DOB Age Sex Race (Please circle one) Ethnicity (Please circle one) White Spanish/Hispanic Origin Black/African American Not of Spanish/Hispanic Origin American Indian Unknown Asian Other Language (Please circle one) English Other Primary Physician¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬ Referring Physician or Nurse if different than Primary Physician Other Physicians You Are Seeing Name Specialty Reason 1) 2) 3) 4) 5) 6) PATIENT INITIAL VISIT DATA (cont.) PAST HISTORY (circle yes or no) Have you ever had a breathing test? Yes No Have you ever had pneumonia? Yes No Have you ever had pleurisy? Yes No Have you ever had a heart attack? Yes No
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