print a new patient packet - Banner Alzheimer's Institute
print a new patient packet - Banner Alzheimer's Institute
print a new patient packet - Banner Alzheimer's Institute
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MEDICAL HISTORY (cont)<br />
PLEASE INDICATE IF THE FOLLOWING ISSUES ARE A PROBLEM.<br />
IF YES, PLEASE DESCRIBE IN THE COMMENT BOX.<br />
GENERAL<br />
SKIN<br />
EYES/EARS<br />
NOSE/THROAT<br />
CARDIOVASCULAR<br />
RESPRITORY<br />
GASTROINTESTINAL<br />
GENITOURINARY<br />
ENDOCRINE<br />
HEMATOLOGICAL<br />
MUSCULOSKELETAL<br />
PSYCHIATRIC<br />
NEUROLOGICAL<br />
OTHER<br />
NO YES<br />
WEIGHT<br />
APPETITE<br />
SLEEP<br />
ENERGY LEVEL<br />
SEXUAL DRIVE/FUNCTION<br />
RASH<br />
VISION<br />
HEARING<br />
TASTE/SMELL<br />
SPEECH<br />
SWALLOWING<br />
HIGH BLOOD PRESSURE<br />
CHEST PAIN<br />
PALPITATIONS<br />
LIGHT-HEADEDNESS<br />
BREATHING<br />
BOWEL MOVEMENTS<br />
DIGESTION<br />
URINATION<br />
THYROID<br />
BLOOD SUGAR<br />
ANEMIA<br />
BLEEDING/BRUISING/CLOTTING<br />
JOINT PAIN/SWELLING<br />
POSTURE<br />
MOOD/MOTIVATION<br />
HALLUCINATIONS<br />
AGRESSION<br />
IRRITABILITY<br />
HEADACHE<br />
DIZZINESS<br />
ALERTNESS<br />
TREMOR<br />
LIMB WEAKNESS<br />
NUMBNESS/TINGLING<br />
BALANCE<br />
OTHER<br />
COMMENTS<br />
Entire <strong>packet</strong> reviewed by: Date: _<br />
Page 5 of 6
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