Purpose of visit
Routine care (date)          Acute illness (date)
Nature of illness
c) Immunization record-Up-to-date? Y or N  Last influenza vaccine (date)
d) Age-appropriate screening by PCP Up-to-date? Yor N
Pediatric issues (check appropriate box)O IZ O Developmental assess O Vision O Hearing O Hypertension O Other
Adult issues (check appropriate box) O Hypertension  O Cholesterol  O Osteoporosis O Cancer screening (cervical, breast, prostate, GI)
Transplant   Other
I. HISTORY -- All historical categories should be compared with previous evaluations
A. Overall Status   
1. How does the patient feel his/her health status compares with last exam? Same/Worse/ Better    Reason
2. Have there been any interim illnesses?
B. Nutrition/Gastrointestinal Manifestations       
1. Dietary intake -- Qualitative dietary history (by recall),  changes in appetite or eating patterns, nutritional supplements, enteral feeds, total parenteral nutrition(TPN),
behavioral issues associated with feeding since previous visit.
A 1-day quantitative dietary history performed by an RD is  recommended for patients with suboptimal nutritional status or  growth, defined as weight less than 90% of lBW height less than 5th percentile, lack of weight gain in 6 months in patients < 18 years of age, or increased nutritional needs.
2. Bowel habits                                             
a) Change in frequency or consistency           
b) Rectal- prolapse (pediatric population)
3. Abdominal symptoms
a) Nausea/vomiting including posttussive
b) Pain - describe location, frequency, relation to meals/stools; associated symptoms leg, flatulence)
c) Bleeding/Upper or lower GI - amount, frequency, associated symptoms
d) Distension - bloating, flatus, constipation
e) Heartburn or symptoms associated with GI reflux
4. Medication usage -- Record type, dosage, frequency for each of the following:
a) Enzymes
b) Vitamins
c) Antacids, H2 blockers, prokinetic agents
d) Ursodeoxycholic acid
e) Over-the-counter medications (laxatives, stool softeners)
f. Nontraditional (naturopathic, herbal), "self-medicated"
C. Respiratory   
1. Cough -- Frequency, severity (including paroxysms), associated symptoms (pain, emesis), awakening at night
2. Sputum production--- Amount, frequency, color, presence of blood
3. Pain -- Upper and lower respiratory tract: frequency, location, description (dull, pleuritic). associated symptoms
4. Upper respiratory symptoms (including sinuses)-- Congestion or obstruction, pain, bleeding, discharge, hoarseness, halitosis, headaches
5. Change in exercise tolerance -- Describe maximum capacity to exercise
6. Shortness of breath (dyspnea)
a) Daytime symptoms
b) Nocturnal symptoms
c)) Associated symptoms - wheezing, -congestion, cough, chest tightness
7. Complications -- Pneumothorax, hemoptysis, pneumonia, allergic bronchopulmonary aspergillosis, asthma, infectious exacerbations
8. Environmental exposures --
Cigarettes, work-related, wood stove, pollens, etc
9. Respiratory treatments
a) Airway clearance techniques (describe type[s] used and frequency)
b) Exercise program
c) Current medications (record type, route, dosage, frequency and duration)
- Antibiotics (ask about allergic reactions to any antibiotics)
-cBronchodilators
- Anti-inflammatory agents (eg, steroids, ibuprofen, cromolyn)
- Mucolytics(eg, rhDNase, acetylcysteine)
- Oxygen (amount and hours/day)
Other
1. Diabetes-related symptoms -- Polyuria, polydipsia, weight loss
2. Reproductive (> 10 years)-- Onset puberty, menstruation, sexual activity, contraceptive history
3) Has the patient seen a primary care provider (PCP) since the last visit?