аЯрЁБс>ўџ ўџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџмЅhcр e€П^2‡70011$1$1$1818181818181H1(81€1Dp1p1p1p1p1~1~1~1~1€1€1€1€1€1€1Ф1X2B€1$1~1p1~1~1~1€1~111p1p1~1~1~1~11 p1$1p1~1€_+ЈУ81811111~1~1~1~1ROS check box if none; circle positive issues and write those issues below: [ ] ALLERGIES TO MEDICATION: [ ] General: Wt change, fever, fatigue, headaches, night sweats [ ] Eyes: eye dz, injury, blurry vision, diplopia, visual loss, discharge [ ] ENNT: ear pain, decreased hearing, tinnitis, rhinorrhea, epistaxis, sore throat, dental pain, voice change, swollen glands [ ] Resp: cough, wheezing, SOB, DOE [ ] CV: palpitation, chest pain, orthopnea [ ] GI: anorexia, BM changes, dysphagia, diarrhea, jaundice, vomiting, nausea, abdominal pain, heartburn, rectal bleeding, constipation [ ] GU: Frequency, dysuria, incontinence, weak urinary stream, dark urine [ ] Males: penile discharge, impotence, libido change [ ] Breast lump/pain/discharge. Vaginal discharge, bleeding, Dyspareunia, LMP:___________ [ ] MS: myalgia, arthralgia, edema, weakness, cramps, back pain [ ] Skin/hair/nails: rash, pruritis, lesions, color change, varicose [ ]Neuro/Psych: numbness, paralysis, memory loss, dizziness, depression, syncope, sleep disturbance, nervousness HISTORY OF PRESENT ILLNESS [ ] For pain issues; see pain questionnaire attached on reverse. [ ] MEDICATION LIST HAS BEEN UPDATED PE: Circle abnormalities, check system if normal (except for those circled). List abnormal and additional findings to the right. T= F; HR= , O2= %on ; RR= , Wt= lbs., Ht= “ [ ] Constitutional: NAD, A&O. Cooperative. [ ]Head: Normocephalic, Atraumatic. Scalp unremarkable [ ]Eyes: Lids, sclerae and conjunctiva clear. PERRLA, EOMI. Non-icteric. No nystagmus. [ ]ENT/Mouth: External ears, canals and TMs clear. Lips gums, oral mucosa are normal. Tongue oral cavity and pharynx clear. [ ] Nose: Nose, septum, turbinates, and nasal mucosa normal. [ ]Neck: Supple and symmetric w/ nrml ROM w/o lymphadenopathy or JVD. No thyroid tenderness nor masses. [ ]Heart: Reg rate & rhythm w/o murmurs, rubs, or thrills. Distal pulses and perfusion adequate. No carotid bruits. [ ]Lungs: No respiratory distress or compromise. CTAB. No wheezes. [ ]Abdomen: soft, flat, without organomegaly, masses or tenderness. Bowel tones present. [ ] Musculoskeletal: Normal gait and station. Extremities are unremarkable, with full active and passive ROM, without atrophy, spasticity or other abnormal movements. Strength symmetrical. No joint swelling, erythema, effusion or tenderness. No crepitation. No dislocation or laxity. Neuro: [ ] Cranial nerves II-XII intact. [ ] DTR biceps, brachioradialis, patellar and ankle, equal and symmetrical bilaterally, [ ] motor and sensory exam. [ ] finger-to-nose; [ ]negative Babinski and Romberg bilaterally. [ ] No tremors Male: [ ]No inguinal hernia palpable w/Valsalva. [ ] Testicles. [ ] Penis. [ ] Rectal: Prostate firm w/o masses nor tenderness. Nrml sphincter tone. [ ]Breasts: Normal shape and contour. Breast development normal without dominant or ominous lesions. No axillary adenopathy. No dimpling, retraction, or skin color/texture changes on breast. Nipples nrml. No discharge. No abnrml masses palpable. [ ] Self breast exam taught in detail using model breast. [ ]Pelvic: Normal ext.genitalia, vaginal wall. No adnexal masses and uterus nrml sized. Good pelvic support without rectocele or cystocele. No excessive discharge or malodor. [ ] Cervix nrml, pap smear taken & sent to pathology. [ ]Psych: Mood, affect and demeanor appropriate. Does not display unusually anxious features. General knowledge, cognition, abstraction, judgement and insight WNL. [ ] Short- and long-term memory intact. [ ] UA:Urobil= Gluc= Ketn= Bili= Prot= Nitrt= Leuk= Blood= pH= SpGrav= 1.0___ ;[ ] Urine preg= ,[ ] Rapid Strep= ,[ ]Glucose= , [ ]H. Pylori= ;[ ] See Anticoagulation notes; [ ] Stool Hemoccult= Assessment/Plan (Rx, consults, testing): Procedures performed (in clinic): EKG, nebulizer, ear lavage, others. Labs ordered(circle): BMP, CMP, CBC, lipids TSH, Free T4, PSA, HbA1C Urine microalbumin, digoxin, INR, arthritis panel, others(specify): [ ]Follow up in ____________ or if sxs do not improve. 1 2 3 4 5 PE Signature for this visit:  HEALTH SCREENING QUESTIONAIRE REVIEW OF SYSTEMS Circle any problems below which you now have, underline any, which you have had in the past. Write details or other comments in the space provided in the right side. General Systems Unexplained fatigue Unexplained weakness Hot/Cold intolerance Unexplained weight loss Unexplained weight gain Unexplained sweats Sores that won’t heal Easy bleeding/bruising Blood transfusion Eyes Color blindness Continuous blurring of vision Double vision Glaucoma Optometrist or ophthalmologist: Dr. ____________________ Ears Hearing loss Continuous ringing of the ears Nose Hayfever Sinus troubles Difficulty with nose bleeds Mouth/Throat Bleeding hums Changes in voice/hoarseness Neck Lumps or “swollen glands” Lungs Frequent or continuous cough Bronchitis Coughed up blood Wheezing in lungs Shortness of breath Asthma Pneumonia Emphysema Tuberculosis Last PPD (TB) skin test: ____________ Abnormal chest x-ray Heart Ankle swelling Heart pain Heart murmur High blood pressure Blood clots Calf/thigh pain with walking Stomach/Bowel Unusual heartburn Vomited blood Frequent/continuous stomach pain Changes in bowel habits Blood in stool Black tarry stools Jaundice Hepatitis Gallbladder disease Ulcers Colitis Diverticulosis Stomach/bowel cancer Cirrhosis Hernia rupture/repair Hemorrhoids Urinary Painful urination Kidney stones Frequent bladder infection Bone/muscle Frequent or continueous joint aches/pains/stiffness Frequent or continuous joint swelling Back pain Muscle pain Gout Nervous system Frequent headaches Loss of consciousness/fainting Seizures/epilepsy Endocrine Thyroid problems Diabetes High cholesterol Skin issues: Emotional/mental. Have you ever received consultation from a mental health professional? (psychologist, psychiatrist, social worker, clergy): For men only: Prostate problems Testicle problems Sexually transmitted disease For women only: Lump in breast Breast cancer Uterus problems Sexually transmitted disease Onset of menses: ____ years old Last periods: / / [ ]check here if not having periods Date of last pap smear: Abnormal Paps? Y N Date of last mammogram: Abnormal mammos? Y N Number of Pregnancies: ____ Number of Birth: _____ Number of miscarriages/abortions: _____ Name:______________________________ Date: / / Patient signature: _______________________________________ Form provided by Roy E. Gondo, MD Follow up issues/conversation (please date and sign) ‘ЁЄа/Ѕр=І8Ї8ЈаЉ*Њ2 (EН K џџџџџџ@fT—œЊЩЮ  ^ h п у  " Œ ‘  J Q Ј З Ц Ы О Т ahš †‹STY[]„ˆ˜ЛМНя№%S\ЫЬмЂ"'TYŽ›ЦЫцьЏЕ(*2nz№џDNz…ћїѕїёїьїьїьїьїьїьїьїьїьїьїьїьїьїьїьїьїѕїьїщчёїчёїспмпйзйззеззззззззззбU^c^cUc^cc uDa]U]]^c]cc]cU]cR…‰™(jz‡МОП§љ§љ§љ§ї§ѕucU^cc LkЎћ}Ѕг_Ћф@„Ь@[\]^_`abcdefЉаT—ЦўZ к  ˆ F Ѓ Ц ­ О ўўўўўўўўўўўўўўљђђђђђђђђђђђђўўўўўўўўўўўўўўўў&(*( * +]\—‚T]ˆ‰Š‹ŒŽ‘’“”•–—˜пр&jkМНОПРСТУФХЦЧШЩЪўўўўўўњѕѕѕѕѕѕѕѕѕѕѕѕѕѕѕѕяяяяяяўўўўўўўўўўўўўўрР!(*( +ЪЫЬЭЮЯабвгдеяёђѓє%ЫЬм№2J]sŠœЂВаоч!"'4STYbўўўўўўўўўўўўўўўўўўўўќўўўўўўўўўўќўўўўўўњўўўјў,bqŽ›ЉХЦЫхць %7KR\fs™ЎЏЕФЯм№ќ(:HiЃЌЖЪбйш§ўўўќўўўќўўќўўўўўўўўўўўўќўўўўўўўќўўўўўўўўўўўўў-§)*2DRmnzЎдоъя№џ1CDN_hyz‡ˆ‰(:Lijz‰—ЇФх/_ўўўўќўўўўќўўўўўўќўўўўќўўўўўўўўўўўўўўўўўўўўўўў-ЌФэю()*e‡МНОПўўўўўўўўўўўўў K@ёџNormala c"@" Heading 1^c$@$ Heading 2U^c"@" Heading 3Uc"A@ђџЁ"Default Paragraph Font @ђ Header рР! @ Footer рР!69ППџџџџ…Ъb§ПяПпџ@DTimes New Roman Symbol "Arial"Arial Narrow"€№аhGSuЦGSuЦ…Дiжп ƒ.№BS: (use approved abbr—contRoy E. Gondo, MDuser ўџџџ§џџџўџџџ&ўџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџўџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџRoot Entryџџџџџџџџ РF€_+ЈУ€WordDocumentџџџџ^2CompObjџџџџџџџџџџџџjSummaryInformation(џџџџџџџџиўџџџ ўџџџ ўџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџўџ џџџџ РFMicrosoft Word Document MSWordDocWord.Document.8є9Вqўџр…ŸђљOhЋ‘+'Гй0Ј˜ Фаьј $0 X d p |ˆ˜ фS: (use approved abbr—contRoy E. Gondo, MDNormaluserО­о2Microsoft Word for WindoDocumentSummaryInformation8џџџџџџџџџџџџ иџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџўџ џџџџ РFMicrosoft Word Document MSWordDocWord.Document.8є9Вqtф g. S: (use approved abbr—contws 95@FУ#@Ю#„bТ@вж‘У@вж‘УжпўџеЭеœ.“—+,љЎ0Ј@HT\ dl tф g. S: (use approved abbr—cont