The purpose of this interactive form is to help you and your doctor focus on your health care during your Cystic Fibrosis Team visit. Please look it over prior to your visit, fill in the blanks if you can, print it and bring it in at the time of your visit, or email it for your team. Just click on the field after the question and choose or write in your answer. You don't need to answer every question. Please ask your doctor or any member of the team to explain any words you don't know.
Why are you coming in today?
When was your last visit with the team? :
If you are coming to clinic because you feel sick today, when did you start feeling sick? :
Nature of illness:
Is your Immunization Record up-to-date? :
Last influenza vaccine (date):
Have you seen your doctor for regular pediatric or adult care not related to cystic fibrosis? (Y or N):
Pediatric issues (Mark Y or N after appropriate box):
High Blood Pressure:
Adult issues (Mark Y or N after appropriate box):
HISTORY -- Compared with previous visits
A. Overall Status
How do you feel your health is compare with your last exam?
Have you been ill since your last visit?
B. Nutrition/Gastrointestinal Manifestations
1. Dietary intake -
Write in a typical breakfast - What you eat, what time you eat, and how much:
Write in a typical lunch - What you eat, what time you eat, and how much:
Write in a typical dinner - What you eat, what time you eat, and how much:
Write in a typical snack - What you eat, what time you eat, and how much:
Have there been any changes in appetite or eating patterns? :
To help you keep on weight are you taking any supplements? :
Any behavioral issues associated with feeding since previous visit?
A 1-day quantitative dietary history needs to be performed by the Registered Dietitian if your team has been worried about nutritional status or growth, defined as weight less than 90% of Ideal Body Weight, height less than 5th percentile, lack of weight gain in 6 months in patients < 18 years of age, or increased nutritional needs. If this has been requested please take the time to include quantities of food in the spaces above.