top of page

SREENING & VITAL SIGNS

I. REVIEW OF SYSTEMS

2. Do you experience any of the following: fever, cough, colds, or headache?
3. Do you experience any of the following: unexplained change in weight, loss of appetite, change in bowel movement, or abdominal pain?
4. Do you experience any of the following: chest pain or difficulty in breathing?
5. Do you experience any of the following: frequent urination, frequent eating, frequent intake of fluids, smoking and drinking alcohol?
6. Do you experience any of the following: pain or discomfort on urination or frequency of urination?
8. Do you experience any of the following: muscle spasm, tremors, weakness; muscle/joint pain, stiffness, limitation of movement?

If the answer is yes to Questions 1-8, the beneficiary needs to consult a doctor.

II. PERSONAL & SOCIAL HISTORY

1. Do you smoke cigar, cigarette, e-cigarette, vape, or other similar products?
2. Do you drink alcohol or alcohol-containing beverages?

III. PAST MEDICAL EXAMINATION

Choose all that applies:
.
.

IV. PERTINENT PHYSICAL EXAMINATION FINDINGS

General Survey:
Blood Type (as available)

Thanks for submitting!

bottom of page