COMMUNITY HOSPITAL EAST ADVANCED WOUND CENTER (AWC) NEW PATIENT MEDICAL HISTORY CHIEF COMPLAINT WHAT IS THE REASON FOR YOUR VISIT TODAY? HISTORY OF PRESENT ILLNESS TELL US ABOUT YOUR WOUNDS: Where is your wound located? How long have you had the wound(s)? How did the wound(s) occur or develop? Describe any signs or symptoms associated with your wound (odor, numbness, drainage, etc…):  Do you have pain in or around the wound(s)?  No  Yes Describe your pain by checking the boxes, below, that apply.  Constant (never goes away)  Aching 

 Burning 

 Cramping  Tender

 Intermittent (comes and goes)

 Throbbing 

 Stabbing 

 Easy to pinpoint

Shooting 

 Sharp 

 Dull 

 Heavy

 Difficult to pinpoint

Describe or list any conditions or activities that impact your wound, such as pain when walking or raising your leg: ______________________________________________________________________________________________ REVIEW OF SYSTEMS (LIST ALL OF YOUR CURRENT COMPLAINTS AND SYMPTOMS) CONSTITUTIONAL (GENERAL HEALTH ) CURRENT COMPLAINTS & SYMPTOMS YES Active Fatigue (tired all of the time)

MUSCULOSKELETAL NO

CURRENT COMPLAINTS & SYMPTOMS YES Backache Contractures

Fever

Deformities

Loss of Appetite

Muscle Pain

Marked Weight Change

Muscle Wasting

Sedentary (low activity level)

Muscle Weakness

Night Sweats

Assistive Devices

EAR / NOSE / MOUTH / THROAT

INTEGUMENTARY (HAIR / SKIN / NAILS)

Hearing Loss / Aid

Pruritis (itching)

Otalgia (ear ache)

Rash

Dental Problems Painful or Swollen Lymph Nodes

18617  05-20-13  PAGE 1 OF 7

NO

Skin Allergies Calluses/Corns

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COMMUNITY HOSPITAL EAST ADVANCED WOUND CENTER (AWC) NEW PATIENT MEDICAL HISTORY EYES

NEUROLOGICAL

CURRENT COMPLAINTS & SYMPTOMS YES

NO

CURRENT COMPLAINTS & SYMPTOMS YES

Blurred Vision

Abnormal Gait

Dry Eyes

Dizziness

Vision Changes

Loss of Protective Sensation

Glasses / Contacts

Numbness

RESPIRATORY

NO

Tremors Cough

Vertigo (dizziness)

Hemoptysis (coughing blood)

Weakness

Shortness of Breath

Headaches

Wheezing

Paralysis

Oxygen in Use

Seizures

CARDIOVASCULAR (CENTRAL / PERIPHERAL)

PSYCHIATRIC

Dyspnea on exertion (shortness of breath with activity)

Anxiety

Edema (swelling)

Claustrophobia

Intermittent Claudication (pain on exertion, i.e. walking to mailbox)

Insomnia

Orthopnea (shortness of breath when lying down)

Nervousness / Tension

Palpitations

Memory Loss

GASTROINTESTINAL (GI)

HEMATOLOGIC / LYMPHATIC

Bowel Incontinence

Bruising

Change in Bowel Habits

Bleeding / Clotting Disorders

Jaundice

Blood Transfusion

Nausea / Vomiting / Diarrhea

ALLERGIC / IMMUNOLOGIC

Loss of Appetite

Rhinitis (inflamed nasal passage) Hay Fever

GENITOURINARY (GU)

ENDOCRINE

Frequency

Cold Intolerance

Urinary Incontinence

Heat Intolerance

Pregnant

Polydypsia (Excessive thirst) Polyuria (Excessive urination)

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COMMUNITY HOSPITAL EAST ADVANCED WOUND CENTER (AWC) NEW PATIENT MEDICAL HISTORY PAST MEDICAL & SURGICAL HISTORY YES

NO

YES

NO

CONSTITUTIONAL (GENERAL HEALTH ) Influenza (Flu) Vaccine Current Tetanus Vaccine Current Pneumonia Vaccine Current Sleep Apnea Implantable port or intravenous catheter History of VRE or MRSA (Portacath or PICC line) EAR / NOSE / MOUTH / THROAT Myringotomy (incision in eardrum) Barotrauma (damage to ear drum) Tube Placement (in ear) Sinusitis

Tinnitus (ringing in ears) EYES Cataract repair Eye Surgery  Left  Right Prosthetic eye

Cataracts Glaucoma Retinopathy (damage to the retina) RESPIRATORY

Pneumonia Pneumothorax (collapsed lung) Positive TB Test Pulmonary Embolus (blood clot in lung) Thoracic surgery Tuberculosis Upper Respiratory Infection (URI) CARDIOVASCULAR (CENTRAL / PERIPHERAL) Coronary Artery Bypass Surgery Congestive Heart Failure Greenfield Filter Coronary Artery Disease (CAD) Left Ventricular Assist Device Deep Vein Thrombosis (clot in the vein) Pacemaker/Defibrillator Hyperlipidemia (High cholesterol) Peripheral Bypass surgery Hypertension (High blood pressure) Stent Placement Murmur Valve Replacement Myocardial Infarction (Heart attack) Vasculitis Peripheral Vascular Disease Venous insufficiency Rheumatic Fever Vein Stripping Subfascial endoscopic perforator surgery (SEPS) GASTROINTESTINAL (GI) Cirrhosis of the Liver Colectomy (remove part large colon) Crohn’s Disease Colostomy Gastro Esophageal Reflux (GERD) Ileostomy Hepatitis (liver infection) Appendectomy Special Diet Fistula repair Ulcerative Colitis Gastric bypass or lap band

Abnormal Chest X-ray Asthma Chest tube insertion Chronic Obstructive Pulmonary Disease (COPD) Emphysema Lung resection Lung transplant

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COMMUNITY HOSPITAL EAST ADVANCED WOUND CENTER (AWC) NEW PATIENT MEDICAL HISTORY YES

NO

YES

NO

GENITOURINARY (GU) Benign Prostate Hyperplasia (enlarged prostate) Dialysis End Stage Renal Disease Kidney Disease

Miscarriage Prostate Cancer Previous OB/GYN Surgery Sexually Transmitted Disease ENDOCRINE

Gestational Diabetes (with pregnancy) Thyroid Disease

Type 1 Diabetes (juvenile onset) Type 2 Diabetes (adult onset)

MUSCULOSKELETAL Achilles Tendon Lengthening Implanted Surgical Hardware Amputation Joint Replacement Arthritis Osteoarthritis Back Surgery Osteomyelitis (bone infection) Foot Surgery Osteoporosis Gout Other Fracture Hip Fracture INTEGUMENTARY (HAIR / SKIN / NAILS) Burn Onchomycosis (nail fungal infection) Malignancy (skin cancer) Scleroderma NEUROLOGICAL Amyotrophic Lateral Sclerosis (ALS) HEAD/SPINAL SURGERY CNS Trauma Injury Multiple Sclerosis Epilepsy Stroke Head Injury / LOC Transient Ischemic Attack (TIA / mini-stroke) PSYCHIATRIC Alzheimer’s Depression Dementia (loss of mental skills) HEMATOLOGIC / LYMPHATIC Anemia (low blood count) Lymphedema Anticoagulant Therapy Sickle Cell Anemia ALLERGIC / IMMUNOLOGIC AIDS / HIV

Reynaud’s Disease

Lupus

Rheumatoid Arthritis

Pyoderma Gangrenosum

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COMMUNITY HOSPITAL EAST ADVANCED WOUND CENTER (AWC) NEW PATIENT MEDICAL HISTORY FAMILY HISTORY YES NO

Which Relative Or Any Pertinent Comments

Cancer Diabetes

Type I: _____ Type II: ____ Heart Disease Hypertension Kidney Disease Lung Disease Mental Illness Seizures Stroke Thyroid Problems Tuberculosis

SOCIAL HISTORY Substance Abuse

 NO

 YES

| DESCRIBE:

Alcohol Use:

 NEVER

 RARELY

 MODERATE

Tobacco Use:

 NEVER

 FORMER

 LESS THAN 1 PACK PER DAY

 RARELY

 MODERATE

Smokeless Tobacco:  NEVER

 DAILY G  REATER THAN 1 PACK PER DAY | YEARS:

 DAILY

Caffeine Use:

 NEVER

 PREVIOUSLY

 CURRENTLY

| TYPE / FREQUENCY:

Illicit Drug Use:

 NEVER

 PREVIOUSLY

 CURRENTLY

| TYPE / FREQUENCY:

Marital Status:  SINGLE  OTHER:

 MARRIED

 SEPARATED

 DIVORCED  WIDOWED

Children

 YES

| IF YES, HOW MANY:

Occupation:

 NO

Cultural, Religious or Language Concerns that may affect your care: Do family and friends provide help when needed?

 NO

 YES

Transportation Concerns (able to drive, etc.)?: Able to Care for Self (dressing, bathing, etc.)?  NO

 YES If “No”, explain :

Do you currently have Home Care or Hospice?  NO

 YES If “Yes”, explain :

ADVANCE DIRECTIVES & INSTRUCTIONS (Check all that apply)  I have an advance directive

 Advance directive materials were provided to me

 I have a living will

 I have a copy of my living will for the hospital

 I have a durable power of attorney for healthcare

 I do not want to be resuscitated

ALLERGIES (List All Known Allergies And Reactions) 18617  05-20-13  PAGE 5 OF 7

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COMMUNITY HOSPITAL EAST ADVANCED WOUND CENTER (AWC) NEW PATIENT MEDICAL HISTORY  No Known Allergies

 Latex / Rubber

 Tape

 Iodine

Food Allergies: Medication Allergies: Other:

MEDICATIONS (List All Medicines You Are Currently Taking -- Include Over The Counter, Herbal & Vitamin Supplements) MEDICATION EXAMPLE:

18617  05-20-13  PAGE 6 OF 7

ASPIRIN

STRENGTH

DOSAGE

HOW OFTEN

325MG

1 PILL

DAILY

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COMMUNITY HOSPITAL EAST ADVANCED WOUND CENTER (AWC) NEW PATIENT MEDICAL HISTORY Nutrition assessment / screen

YES

Difficulty chewing or swallowing?

[1]

Do you need assistance with eating?

[1]

NO

GENERAL NOTES:

Have you had a weight loss or gain > 10 lbs in past 6 mo? [2]

Reason, if known:

If yes, ______ lbs in _____ months Intentional weight loss from program or medications?

[1]

Do you follow a special diet?

[1]

Do you have any food allergies?

[1]

Do you have a good appetite? 

[0]

Do you have a fair appetite? 

[1]

Do you have a poor appetite?

[2]

Do you take nutritional supplements?

[0]

Do you drink several 8 oz glasses of water each day? RISK LEVEL:  Low = less than or equal to 2  | High = greater than 3 

[0] (Staff Use Only)

SCORE:

PATIENT SIGNATURE: _________________________________________

DATE: ___________

TIME: 

(OR LEGAL GUARDIAN/POA)

I have reviewed the new patient medical history with the patient / caregiver as part of the initial nursing assessment. NURSE SIGNATURE: ___________________________________________

18617  05-20-13  PAGE 7 OF 7

DATE: ___________

TIME: 

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