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What is a man? An individual human adult male more than 18 years old. What medical history is required of a man who needs nonemergency doctor consultation? What best describes your problem?
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Address Activities of everyday living Annual health assessment Assets Abilities/skills Complaint/problem Communications Duties Detention Education Hospitalization Impairment Rating and Disability Determination Language Photograph Profession Referrals Survival Needs Stress 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? _________________________ 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? _________________________ 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. _________________________ 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 _________________________ These are basic questions. There are many more. |