Patient history form

Shortly thereafter I called to make an appointment with an environmental physician in Mobile, Alabama, the closest environmental physician to Baton Rouge at that time. I was told I could not be seen until I completed a very extensive patient history form which they would mail to me, and they wanted a picture of me. After I completed that history I started making connections for the first time. 

Care-Rite Pharmacy Patient Medical History Form... 

Figure 25-3. Care-Rite Pharmacy patient medical history form.

After performing a SWOT analysis and some baseline market research, Carol and the other pharmacists at Care-Rite Pharmacy have decided to develop a Pharmacy Check-up Service (MTM). One of Carol s pharmacists volunteered to put together a prototype patient chart that will be used by the pharmacists to document their activities. The patient chart contains several forms, including a patient history form that requests some basic demographic information (see Fig. 25-2), medical and medication histories forms (see Figs. 25-3 and 25-4), and an authorization to release medical information that is signed and dated by the patient (see Fig. 25-5). Also, a communication form was created to fax clinical information and pharmacists recommendations to the physician (Fig. 25-6). 

Many sources have good examples of patient data collection forms.An example of a patient history form is given in Fig. 1. The format of the form will require modification for the specific care setting and goals of the individual practitioner. 

A nuclear medicine physician fills out a scheduled patient s history form indicating where the scan begins and ends on the body. 

The shortcomings in these areas include incomplete and inconsistent medication history in patient charts, pharmaceutical care not provided routinely, large number of abbreviations used on preprinted forms and in medication communications (verbal and written), medication brands changed without the knowledge of surgical teams or technicians, hazardous chemical found in close proximity to products designated for patient use, top of anesthesia carts cluttered, medication "stashes" found in selected areas, inconsistent preoperative teaching of patients, and inconsistent system of double-checks [10]. 

Connective tissue disorders such as SSc, LE, Sjogren s syndrome, dermatomyositis and RA can be induced by occupational exposure to silica, solvents, and other chemical offenders. An enhanced genetic susceptibility seems to favor these disorders. SSc is the most frequent and best-studied disease. While silica precipitates SSc, the other offenders induce scleroderma-like diseases with different clinical and laboratory findings than with SSc. Taking a careful case history of patients with SSc will help to identify the occupational causes. The best way to prevent this type of connective tissue disease is to minimize the exposure to occupational substances. However, efforts in the form of individual expert decisions have to be made in order to acknowledge these disorders as occupational diseases and provide some social and financial support to patients and reduce the harm caused by these disorders. 

Extrapyramidal effects A group of American authors claim that akinesia, a form of extrapyramidal reaction to phenothiazine and related drugs, occurs far more often than is generally recognized. They support their claim with a series of case histories of patients suffering from a variety of serious... 

NIDDM is a much more common disease than IDDM, accounting for about 85—90% of all cases of diabetes meUitus. Whereas NIDDM may be present at any age, the incidence increases dramatically with advanced age over 10% of the population reaching 70 years of age has NIDDM. Patients with NIDDM do not require insulin treatment to maintain life or prevent the spontaneous occurrence of diabetic ketoacidosis. Therefore, NIDDM is frequendy asymptomatic and unrecognized, and diagnosis requires screening for elevations in blood or urinary sugar. Most forms of NIDDM are associated with a family history of the disease, and NIDDM is commonly associated with and exacerbated by obesity. The causes of NIDDM are not well understood and there may be many molecular defects which lead to NIDDM. 

There are few definitive data to substantiate the efficacy of LTRA therapy in refractory asthma, except for patients with aspirin-sensitive asthma. This is a fairly uncommon form of asthma that occurs generally in adults who often have no prior (i.e., childhood) history of asthma or atopy, may have nasal polyposis, and who often are dependent upon oral corticosteroids for control of their asthma. This syndrome is not specific to aspirin but is provoked by any inhibitors of the cycloxygenase-1 (COX-1) pathway. These patients have been shown to have a genetic defect that causes... 

As discussed later in this chapter, contraindications exist for various forms of contraception. Patients must be evaluated completely by a health care professional to rule out any medical contraindications to certain contraceptives. The physical examination also will allow health care professionals to determine if there are other medical concerns, such as hypertension, diabetes, or liver disease, that need to be considered when determining the appropriate contraceptive agent. Clinicians also should review family history for potential risks with certain forms of birth control. 

Like concomitant medication data, patient medical history data are collected in one of two forms a list-type free-text format where the histories get coded, or a pre-categorized data format. Here is the free-text CRF format ... 

Major Depressive Disorder with Psychotic Features. One severe subtype of depression is characterized by both depressive and psychotic symptoms. Unless a longitudinal history is available, it can be difficult to distinguish a patient with a psychotic depression from a depressed patient who has a comorbid Cluster A personality disorder. Some qualitative features may be helpful, but these are not wholly reliable. The most prominent psychotic symptoms of a psychotic depression tend to be delusions and auditory hallucinations, but these sometimes present in an attenuated form more reminiscent of Cluster A symptoms. 

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