Form Form General Checkup Height weight Nurse I

Form

Form

General Checkup

Height/ weight Nurse : I will measure you height. Nurse : Please step on here. Nurse : Please stand up straight while pressing your head backward and pulling your chin forward. Nurse : Now please step on this scale. I will measure your weight. Nurse : You are 5’ 7’’ and you weigh 135 pounds.

Blood pressure Nurse Nurse : : : I will check your blood pressure. Please give me your right arm. Your blood pressure is 00 over 00. Your blood pressure is higher than normal. I will double check from your left arm.

The consultation

Greeting and identification • Good morning, Mr. Davis. Please take a seat. • Come in and sit down, Mrs. Green. • I am Dr. Kim. • Dr. Sampson wrote to me about your current condition.

Present complaint • • • Now, Mr. Willson, what can I do for you? What is troubling you? What’s brought you here? What seems to be the problem? Well, Mrs. Davis, I’ve read the letter from your doctor and he tells me you’ve been having headaches. • Now, Mr. Hicks, what’s brought you along here today? • Well, what can I do for you today?

Taking a History • • • How long have you had this pain? How long have they been bothering you? Where is the pain exactly? Can you show me where it hurts? When did you first notice this? When did the trouble first start? How long has this been going on? How long have you had this problem? Does the pain have any relation to…. ? Does it bother you when you are…. . ? Do you ever feel like vomiting?

Taking a past and current History • • • Have you ever had chicken pox? Did you ever have any fractures? Have you ever been operated on? Have you ever had any tonsils out? How about your bowels? Have you ever had any problems? • Have you had any illnesses, hospitalizations, or surgeries that we are not already aware of?

• Have you had any reactions to medications or immunizations? • Are you taking any medications? • Are you taking any supplements, “alternative” medicines or therapies? • Do you have good appetite? • Do you eat a variety of foods(fruits, vegetables, grains, protains)?

Taking a family History • • Are your parents alive? Are your folks living? Do you have any brothers or sisters? Can I ask you about your parents? Are they …? Are your parents in good health? Does your husband smoke(drink)? What did your parents die of? When did your wife die? • Is there any family history of sudden cardiac death or arrhythmias? • Are there any major illnesses in the family?

Taking a Social History? • Do your parents live with you? • Are there any major changes or stresses in the family? • Are you married? • Do you have any children?

I, Undersigned, certify that I(or my dependent) has insurance coverage as above, and assign directly to Dr. Dennis Kim all insurance benefits. if any, otherwise payable to me for service rendered, I understand that I am financially responsible for all charges whether or not paid by insurance. I hereby authorize the doctor to release all information necessary to secure the payment of benefits. I authorize the use of this signature on all insurance submissions.