RAO V.SUNKAVALLY M.D.,F.A.C.S. PATIENT HISTORY FORM UROLOGY (Sheet 1/5 of NewPt H&P Revised 2/2011) LAST NAME_________________________________ FIRST NAME_____________________ TODAY’S DATE__________TIME_____ DATE OF BIRTH__________________ REFERRING DOCTOR_____________________________ LAST EXAM DATE ____________ CHIEF COMPLAINT: What is the main reason for your visit today? ( Describe your problem in detail including duration) ______________________________________________________________________________________________________________ _____________________________________________________________________________________________________________ HISTORY OF PRESENT ILLNESS: ♦Note: Please answer the following questions in detail! 1.Location of the problem: Other____________________________________ 2.Quality: Is the problem Constant or Variable? Dull, then Sharp Very Sharp then leaves Always there Other_______________________________________________ 3.Severity: On a Scale of 1-10, with 10 being the most severe, Check the number that best describes the severity of problem? 4.Duration: When did you first notice the problem? Two days ago 2 weeks ago 2 months ago Other___________________________________________________________ 5.Timing: How long does the problem last? It is always there Other______________________________ 6.Context: Does the problem interfere with your normal functions? No If Yes, please explain_______________________________________________________________________________ 7.Modifying Factors: Does anything help or make the problem worse? Moving around Standing up Lying on my side Other______________________________________________________ 8.Associated Signs & Symptoms: Is there anything else occurring at the same time? No. If Yes please explain below: Headaches Other________________________________________________________________________ PAST, FAMILY & SOCIAL HISTORY
♦Medications: Please list all medications you are currently taking. DRUG NAMES DOSE START DATE DRUG NAMES DOSE START DATE ________________________ _____________ ____________ _______________________ _____________ ______________ ________________________ _____________ ____________ _______________________ _____________ ______________ ________________________ _____________ ____________ _______________________ _____________ ______________ ________________________ _____________ ____________ _______________________ _____________ ______________ PAST MEDICAL HISTORY:♦List any personal past Illnesses and or Surgeries and when they occurred.
ILLNESS OR SURGERY DATE ILLNESS OR SURGERY DATE Hypertension. High cholesterol. ____________ ___________________________________ ____________ ___________________________________________ ____________ ___________________________________ ____________ ___________________________________________ ____________ ___________________________________ ____________ ♦ALLERGIES: Do you have any allergies to medicines or food ? No Yes. IF YES, PLEASE LIST BELOW: PENICILLIN. MACRODANTIN. OTHER: _____________________________________________________ FAMILY HISTORY: ♦List all serious Illnesses in your Immediate family.
YES NO RELATION YES NO RELATION YES NO RELATION/ TYPE OF CANCER Heart Disease ____________ Diabetes ____________ Cancer _____________________________ High Blood Pressure ____________ Stroke ____________ Other _____________________________
♦Do you Drink Alcohol? No Yes. What do you drink?_________________ How much?______________ Quit Date:__________
♦Do you Smoke Cigarettes? No Yes.How much?______________ Quit date:_________ How long were you smoking?______ PHYSICIAN USE ONLY:(Comment/Notes)____________________________________________________________________________________ ________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________ NEW PATIENT HISTORY OF PRESENT ILLNESS (1-3 = 1 or 2; 4+ = 3-5)PFSH ( 0 = 1 or 2; 1-2 = 3; 3 = 4 or 5) Page 1 OVER RAO V.SUNKAVALLY M.D.,F.A.C.S. REVIEW OF SYSTEMS UROLOGY (sheet 2/5 of NewPt H&P Revised 2/2011)
♦Do you now have or have you had any of the following problems? Please explain any “Yes” answer CONSTITUTIONAL SYMPTOMS: 1.Fever Y 2.Chills Y 3.Weight loss Y 4.Headaches Y 5.Other __________________________________ _____________________________________________________________________________________________________________ EYES: 1.Blurred Vision Y 2.Double Vision Y 4.Other _____________________________________________ _____________________________________________________________________________________________________________ EARS/NOSE/MOUTH/THROAT: 1.Hearing loss Y 2.Hay fever Y 3.Loss of Smell Y 4.Sinus Problem Y 5.Other__________________ _____________________________________________________________________________________________________________ CARDIOVASCULAR: 1.Chest Pains Y 2.Irregular Heart Beat Y 3.Varicose Veins Y 4.Other _________________________________ _____________________________________________________________________________________________________________ RESPIRATORY: 1.Wheezing Y 2.Frequent Cough Y 3.Shortness of Breath Y 4.Other ________________________________ _____________________________________________________________________________________________________________ GASTROINTESTINAL: 1.Abdominal Pain Y 2.Nausea/Vomiting Y 3.Constipation Y 4.Other_________________________________ _____________________________________________________________________________________________________________ GENITOURINARY: 1.Urine Retention Y 2.Painful Urination Y 3.Blood in Urine Y 4.Other_________________________________ _____________________________________________________________________________________________________________ MUSCULSKELETAL: 1.Joint Pain Y 2.Neck Pain Y 3.Back Pain Y 4.Back Injury Y 5.Other___________________________ _____________________________________________________________________________________________________________ INTEGUMENTARY: 1.Skin Rash Y 2.Persistant Itch Y 3.Boils Y 4.Other______________________________________________ _____________________________________________________________________________________________________________ NEUROLOGICAL: 1.Tremors Y 2.Dizziness Y 3.Numbness/Tingling Y 4. Other_______________________________________ _____________________________________________________________________________________________________________ PSYCHIATRIC: 1.Depression Y 2.Anxiety Y 3.Suicidal Tendencies Y 4.Other______________________________________ _____________________________________________________________________________________________________________ ENDOCRINE: 1.Excessive Thirst Y 2.Too Hot/Cold Y 3.Tired/sluggish Y 4.Other___________________________________ _____________________________________________________________________________________________________________ HEMATOLOGIC/LYMPHATIC: 1.Swollen Glands Y 2.Blood clotting Problem Y 3.Anemia Y 4.Other________________________________ _____________________________________________________________________________________________________________ ALLERGIC/IMMUNOLOGIC: 1.Hay Fever Y 2.Other____________________________________________________________________________________ PHYSICIAN USE ONLY: (Comments/Notes)____________________________________________________________________________________ __________________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________________ NEW PATIENT REVIEW OF SYSTEMS (0-1 = 1 or 2; 2-9 = 3; 10+ = 4 or 5 ) PHYSICIAN SIGNATURE OR INITIALS______________ DATE:______________
Application of Case Based Reasoning to Legacy System Migration J. Grimson, B. Wu, J. Bisbal, and D. Lawless 1. Introduction Systems migration is now a major issue in established IT departments, [Bene95, Wins94]. Typically the information systems of these organisations are large, old, mission critical, and have minimal, if any, documentation. These information systems define what we today ca