AGGRAVATING FACTORS What treatments, activities, foods, settings, etc. make the problem WORSE? RELIEVING FACTORS What treatments, activities, foods, settings, etc. make this issue BETTER? ASSOCIATED SYMPTOMS Are other symptoms that come on with or after this? PROGRESSION Is the problem generally getting worse, better, or not changing? FAMILY HISTORY Have you or a family member had a similar concern in the past? YOUR OPINION Even if you are not 100% sure, what do you think is causing and/or perpetuating this problem? ADDITIONAL INFORMATION Please give any other information you feel is important to fully understand your concern. PRIMARY health concern #2 CONCERN #1 Name the diagnosis, symptom or concern. LOCATION & QUALITY If applicable, name the location and quality of the symptom (sharp, dull, constant, etc.). ONSET & CAUSES When did this What events preceded the symptom? “I’ve never been well since I ___.” SEVERITY Rate the intensity 0-10: 0 = perfect 10 = worst imaginable FREQUENCY & DURATION How frequently does it occur? How long does symptom last when it is present? TIMING Is the problem at any particular time (day/week/month/season)? TRIGGERS Is there anything in particular that triggers this issue? AGGRAVATING FACTORS What treatments, activities, settings, etc. make the problem WORSE? RELIEVING FACTORS What treatments, activities, settings, etc. make this issue BETTER? ASSOCIATED SYMPTOMS Are there other symptoms that come on with or after this?
PROGRESSION Is the problem generally getting worse, better, or not changing? FAMILY HISTORY Have you or a family member had a similar concern in the past? YOUR OPINION Even if you are not 100% sure, what do you think is causing and/or perpetuating this problem? ADDITIONAL INFORMATION Please give any other information you feel is important to fully understand your concern. PRIMARY health concernS #3 CONCERN #1 Name the diagnosis, symptom or concern. LOCATION & QUALITY If applicable, name the location and quality of the symptom dull, constant, etc.). ONSET & CAUSES When did this start? What events preceded the symptom? “I’ve never been well since I ___.” SEVERITY Rate the intensity 0-10: 0 = perfect 10 = worst imaginable FREQUENCY & DURATION How frequently does it How long does symptom last when it is present? TIMING Is the problem worse at any particular time (day/week/month/season)? TRIGGERS Is there anything in particular that triggers this issue? AGGRAVATING FACTORS What treatments, activities, foods, settings, etc. make the problem WORSE? RELIEVING FACTORS What treatments, activities, foods, settings, etc. make this issue BETTER? ASSOCIATED SYMPTOMS Are there other symptoms that come on with or after this? PROGRESSION Is the problem generally getting worse, better, or not changing? FAMILY HISTORY Have you or a family member had a similar concern in the past? YOUR OPINION Even if you are not 100% sure, what do you think is causing and/or perpetuating this problem?
TIMELINE of SIGNIFICANT Medical & LIFE EVENTS Please list and describe all significant Medical & Life Events. Please indicate the EVENT TYPE and list a start date. TITLE EVENT TYPE START DATE (Month &Year) END DATE (If applicable) DESCRIPTION ADDITIONAL INFORMATION: LAB TEST & IMAGING STUDIES Please locate your previous lab and imaging studies—and have them faxed, emailed, or mailed in. In the below, please enter the most relevant results in chronological order (recent first).