ࡱ> :<9Y bjbjWW @==]$lhhhhhhhh$ ~hhhhhPhhhPPPhhhhPzPhL&]". HEALTH RECORDCHRONOLOGICAL RECORD OF MEDICAL CAREDATESYMPTOMS, DIAGNOSIS, TREATMENT, TREATING ORGANIZATION (Sign each entry)Provider:62nd Medical Group (AMC), McChord AFB, WA, 98438Date:Headache Overprint Time:S: ______ y.o. M / F presents with c/o headache for _______ hours / days. B/P:Onset of headache was sudden / gradual, and began while the pt. was:Pulse:Pain began in the frontal / parietal / temporal / occipital area(s) of the L / R / both sideResp:Initial pain rated ____/10, current pain is a ____/10, and the pt. describes it as throbbing / steady / sharp /Temp:dull / other: . Current pain is in the ___________________ on the R / L / B.Ht: Pt. also notes: photophobia / phonobia / nausea / emesis / runny nose / blurred vision / scotoma / fatigue Wt: Fever / chills / stiff neck / weakness in arms or legs / numbness in feet or hands / trouble talkingAge: Perspiration / palpitations / anxiety / sinus congestion / cough / neck pain / reddened eyes / jaw painTobacco: YES NO Current symptoms have improved / not changed / worsened since the start of the headacheLMP: Interventions tried for this headache:Last Pap: Past h/o headaches: never / occassional / frequent, and they were similer / different from current headacheTetanus: If different from current, how so:Allergies: Past headaches tended to last __________, and were usually relieved by ___________________________ Possible triggers: Past attempts at treatment and effectiveness:Meds: Past evaluations: Associated with menses / weather changes / seasonal changes / exertion / smoke / alcohol / stress / meds: Family h/o headaches: Impact of headache on daily life:  Current occupation: Current sleep patterns:Tech: Personal h/o depression Y / NPATIENTS IDENTIFICATION (Use this space for Mechanical Imprint)RECORDS MAINTAINED AT:PATIENTS NAME ( Last, First, Middle initial )SEX RELATIONSHIP TO SPONSOR: STATUSRANK/GRADESPONSORS NAME ORGANIZATIONDEPART./SERVICE SSN/IDENTIFICATION NO.DATE OF BIRTH DATESYMPTOMS, DIAGNOSIS, TREATMENT, TREATING ORGANIZATION (Sign each entry)Provider:Headache Overprint, cont.Date:O: WDWN NAD Fatigued Somnolent Mild distress Moderate distress Severe distressTime: Cranium: normocephalic / abnormal shape: NT / TTP over:B/P: atraumatic / evidence of trauma: Temporal Arteries normal/tender R / L Pulse: Eyes: PERRLA / anisochoric on R / L / unresponsive B; EOMI B / discordant in: Resp: nystagmus on : Conjunctivae are clear / red / cloudy / other:Temp: Visual Acuity: ____/20 OS _____/20 OD ____/20 OUHt: Fundi are clear / cloudy / pigmented / other:Wt: Optic discs are sharp / hazy / edematous on R / L / B Optic cups are normal / deep on R / L / BAge: Ears: normal / otitis externa on R / L / B : TMs red / retracted / serous effusion / pus / bulging on R / L Tobacco: YES NO Oral: benign / tonsils enlarged / erythematous / pus / post-nasal drainage / dental caries inLMP: Nose: benign / edematous mucosa / erythematous mucosa / drainage (clear / pustular)Last Pap: Sinuses: TTP over maxillary / frontal / ethmoid on R / L / B Tetanus: Mandible: NT / TTP over: TMJ NT / TTP / Crepitus on R / L / BAllergies: Neck: supple / stiff NT / TTP over: Ademopathy none / present: Carotids: upstrokes full / decreased on R / L / B, bruits absent / present on R / L / B CV: RRR w/o g/m/r, S3 / S4, Rub: Murmur:Meds: Lungs: Non-labored, CTA; Labored: Wheezes / Rales / Rhonchi over: Neuro: Alert / Somnolent / Obtunded Oriented X ____/4 CN 2-12 intact and equal B / CN absent / decreased on R / L / B Grip ____/5 on R, _____/5 on L; Able to walk on heels / toes / unable to walk on heels / toes on R / L / B Sharp / Vibratory intact and equal / decreased / absent B / L / R at fingers / toes / other: DTRs:Tech: Other:A: Migraine / Tension / Cluster / Mixed / Headache secondary to:P: Meds: Labs: cbc, chem 7, u/a, tsh, serum / urine tox screens, other: Rads: Other: F/U:P: STANDARD FORM 600 BACK (REV. 5-84) (EF-V1) 345p./4yzVW]PQU<=PV W `    I J P f g h ɿɻɬɬɬɬɬɬɬɬɬɬɬɬɬɬɬɬCJEHEH EHOJQJ5EH5CJEHOJQJ CJOJQJ EHOJQJ6CJEHOJQJCJEHOJQJOJQJ 5OJQJ5CJOJQJEHD45:8bl/$$TH    0F<)$-D-$$l    0*-$$l    0*    $$-D$ 45:-./4yzVW]PQU<=FPV W `    I J P f g h P Q R # 7 ; < = > m q r      \-./4yzVW]T, x$-D x$-Dx$-D$-D1$$THH    0\($x$-D$]PQU<=FPV W ¸x$-D$-D1$$THH    0\( x$-DW `    I J P f g h dt t1$$THH    0\(x$-D$-D P Q R  " # 7 ; = > M l m q r s t û˯˯{q5CJH*OJQJ CJOJQJ5CJEHH*OJQJ5CJEHOJQJ5CJEHOJQJ56CJEHH*OJQJ5CJEHH*OJQJ5CJOJQJ5CJOJQJOJQJ6CJEHOJQJ6CJEHOJQJCJEHOJQJCJEH CJOJQJ EHOJQJ, P Q R # 7 ; < hƘƬl$$-D$1$$THH    0\(  $-D1$$THH    0\(x$-D< = > m q r s t 8$$l    F& # )$$-D:$$l    F& K ) r s t F G Q j k l r v ABG  klr%&*abfST]g,-7{|}tuv-.4#$%  a |z8$$l    F&  )$$-DC$$l    \& # ) 4 E Q j k l r v ABG  klr%&*abfSTg,-7|}tuv-.4#$%&(*jlnvxKMCJ CJOJQJ56CJOJQJ CJOJQJOJQJX F G Q k {r$x$-D$-D-$$l    0*$$-D-DE$$l    \& K# )   k l r ABG  klr%&*abϤϴ,|x$-D$-D/$$HH    0*bfST]g,-7{|}tÀ@/$$HH    0*x$-D$-Dtuv-.4#$%όXϸ$ϠDx$-D$-D/$$HH    0*&'(jklvwxKLMPX0äð/$$HH    0*x$-D$-D&'(*jklnvwxKLMPQ MPQZ6CJOJQJ CJOJQJOJQJ CJOJQJ5PQ-D/$$HH    0*  / =!"#$% [(@(NormalCJmH F@F Heading 1 $-D@&5CJEHH*OJQJH@H Heading 2$$-D@&5CJEHOJQJD@D Heading 3$$x-D@& 5CJEH<A@<Default Paragraph Font>B@> Body Text $-D5CJOJQJ@ M ]W < k btP r  <C,3JN T ^ ( 3 l p { 3 8  "*elYc.2 ptMNMPQhq sean s stout*C:\TEMP\AutoRecovery save of Document1.asd sean s stoutA:\ headache overprint.doc sean s stout5C:\TEMP\AutoRecovery save of headache overprint.asd sean s stout5C:\TEMP\AutoRecovery save of headache overprint.asd sean s stout5C:\TEMP\AutoRecovery save of headache overprint.asd sean s stoutA:\ headache overprint.docSteve Alan OliverTC:\Program Files\Microsoft Office\Templates\SF 600 Overprints\Headache overprint.dot@y @GTimes New Roman5Symbol3& Arial"phEE[*"Y20d HEALTH RECORD sean s stoutSteve Alan OliverOh+'0 $ @ L X dpxHEALTH RECORDoEAL sean s stoutoeanHeadache overprintSteve Alan Oliver2evMicrosoft Word 8.0@F#@""@Q@Q՜.+,D՜.+,< hp  USAFR" HEALTH RECORD Title 6> _PID_GUIDAN{F7228887-6E45-11D2-B777-00E029028A6E}  "#$%&'(*+,-./02345678;Root Entry Fధ]]=1Table!WordDocument@SummaryInformation()DocumentSummaryInformation81CompObjjObjectPool@]@]  FMicrosoft Word Document MSWordDocWord.Document.89q