2. Bowel habits
Any changes in frequency or consistency?:
Rectal  prolapse? 

3. Abdominal symptoms
Any nausea or vomiting including after coughing?:

Pain - describe location, frequency, relation to meals/stools; associated symptoms such as passing gas:

Any bleeding? Upper or lower GI - amount, frequency, associated symptoms:
Distension - bloating, flatus (gas), constipation:
Heartburn or symptoms associated with reflux?:

4. Medication usage -- Record type, dosage, frequency for each of the following:

Antacids, H2 blockers (Tagamet, Zantac), prokinetic agents:
Ursodeoxycholic acid (Actigall):
Over-the-counter medications (laxatives, stool softeners):
Nontraditional (naturopathic, herbal), "self-medicated":

C. Respiratory   

Cough: Frequency, severity (including paroxysms), associated symptoms (pain, emesis), awakening at night

Sputum production: Amount, frequency, color, presence of blood

Pain: Sinuses, throat, nose, and chest: frequency, location, description (dull, pleuritic) associated symptoms:

Upper respiratory symptoms (including sinuses)-- Congestion or obstruction, pain, bleeding, discharge, hoarseness, bad breath, headaches:

Change in exercise tolerance -- Describe your maximum capacity to exercise:

Any shortness of breath (dyspnea)?:

Daytime symptoms:

Night time symptoms:

Associated symptoms: wheezing, -congestion, cough, chest tightness

Complications -- Pneumothorax, hemoptysis, pneumonia, allergic bronchopulmonary aspergillosis, asthma, infectious exacerbations

Environmental exposures (Cigarettes, work-related, wood stove, pollens, etc.):

Respiratory treatments

Airway clearance techniques (describe type[s] used and frequency):

Exercise program:

Current medications ( type, route, dosage, frequency and duration)
1. Name
How often?
How long?
How often?
How long?
How often?
How long?
Any allergic reactions to any antibiotics?

Bronchodilators :

Anti-inflammatory agents (steroids, ibuprofen, cromolyn):

Mucolytics(eg, rhDNase - Pulmozyme , acetylcysteine - Mucomyst):

Oxygen (amount and hours/day):

D. Other

Diabetes-related symptoms:  Urinating too much, drinking what seems like too much water, weight loss

Reproductive (> 10 years)-- Onset puberty, menstruation, sexual activity, contraceptive history
Have you seen your primary care provider since the last visit?

Introduction to Outpatient Care | Preventive and Maintenance Care  | Physical Examination  | Interventions: Medications And Supplements | Patient Education | Functional Psychosocial | Case Management | CF Preventive and Maintenance Care (1)
Patient Home Worksheet | CF Preventive and Maintenance Care (2)
Patient Home Worksheet | CF Preventive and Maintenance Care (3)
Patient Home Worksheet

To contact us: landon@rain.org
Phone: 805-289-3333 Fax 805-289-3310