What treatments, activities, AGGRAVATING foods, settings, etc. make the FACTORS problem WORSE? What treatments, activities, RELIEVING foods, settings, etc. make this FACTORS issue BETTER? ASSOCIATED Are other symptoms that SYMPTOMS come on with or after this? Is the problem generally getting PROGRESSION worse, better, or not changing? Have you or a family member FAMILY had a similar concern in the HISTORY past? Even if you are not 100% sure, YOUR what do you think is causing OPINION and/or perpetuating this problem? Please give any other ADDITIONAL information you feel is INFORMATION important to fully understand your concern. PRIMARY health concern #2 Name the diagnosis, symptom or CONCERN #1 concern. If applicable, name the location LOCATION and quality of the symptom & QUALITY (sharp, dull, constant, etc.). When did this What events ONSET & preceded the symptom? CAUSES never been well since I “I’ve ___.” Rate the intensity 0-10: SEVERITY 0 = perfect 10 = worst imaginable How frequently does it occur? FREQUENCY How long does symptom last & DURATION when it is present? Is the problem at any TIMING particular time (day/week/month/season)? Is there anything in particular TRIGGERS that triggers this issue? What treatments, activities, AGGRAVATING settings, etc. make the problem FACTORS WORSE? What treatments, activities, RELIEVING settings, etc. make this issue FACTORS BETTER? ASSOCIATED Are there other symptoms that SYMPTOMS come on with or after this?
AGGRAVATING FACTORS What treatments, activities, foods, settings, etc. make the problem WORSE? RELIEVING FACTORS What treatments, activities, foods, settings, etc. make this issue BETTER? ASSOCIATED SYMPTOMS Are other symptoms that come on with or after this? PROGRESSION Is the problem generally getting worse, better, or not changing? FAMILY HISTORY Have you or a family member had a similar concern in the past? YOUR OPINION Even if you are not 100% sure, what do you think is causing and/or perpetuating this problem? ADDITIONAL INFORMATION Please give any other information you feel is important to fully understand your concern. PRIMARY health concern #2 CONCERN #1 Name the diagnosis, symptom or concern. LOCATION & QUALITY If applicable, name the location and quality of the symptom (sharp, dull, constant, etc.). ONSET & CAUSES When did this What events preceded the symptom? “I’ve never been well since I ___.” SEVERITY Rate the intensity 0-10: 0 = perfect 10 = worst imaginable FREQUENCY & DURATION How frequently does it occur? How long does symptom last when it is present? TIMING Is the problem at any particular time (day/week/month/season)? TRIGGERS Is there anything in particular that triggers this issue? AGGRAVATING FACTORS What treatments, activities, settings, etc. make the problem WORSE? RELIEVING FACTORS What treatments, activities, settings, etc. make this issue BETTER? ASSOCIATED SYMPTOMS Are there other symptoms that come on with or after this?
trmorrisnd-new-patient-intake.docx