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Profile from birth until now
What should I know about you?
What should be included in the profile of a patient?
Patient profile should have all the facts.
The more facts that are available about a patient, the better diagnosis and treatment are possible.

Where is your profile from your birth until now?

_________________________

If your profile is available, you do not need to answer these questions.
If your profile is not maintained with me, you need to answer these questions.
If you have difficulty elaborating your profile, you can be helped with sample examples.

This is how you need to elaborate your profile.

Address
Activities of everyday living
Annual health assessment
Assets
Abilities/skills
Allergies
Complaint/problem
Communications
Duties
Detention
Education
Habits
Hospitalization
Impairment Rating and Disability Determination
Language
Last updated
Photograph
Profession
Referrals
Survival Needs
Stress
Surgical History
Travel history

What is your name?
_________________________

What is your date of birth?
_________________________

Where and when were you born?
_________________________

What is your gender?
_________________________

Address

What is your mailing address?

________________________

________________________

________________________

________________________

Where are you located now?

________________________

What was your mailing address from birth until now?
_________________________

_________________________

_________________________

_________________________

Where do you live now?
_________________________

How long have you lived at this address?
_________________________

What is your contact information including current mailing address, telephone, e-mail, and any other details, and person to contact in case of emergency?
_________________________

_________________________

_________________________

_________________________

_________________________

_________________________

How long do you plan to live at this address?
_________________________

What years did you go to high school?

_________________________

What years did you go to college?

_________________________


Activities of everyday living

What is your normal day like?
_________________________

What do you normally enjoy doing?
_________________________


Annual health assessment

When was your last annual health assessment done?
_________________________

Who did your last annual health assessment?
_________________________

What were the findings?
_________________________

What were the recommendations?
_________________________

Did the recommendations help?
_________________________

Was it an annual health assessment or evaluation of a new problem?
_________________________

When did you last see a medical doctor?
_________________________

Did you see a medical doctor for an annual health assessment or a new problem?
_________________________

What seemed to be the problem?
_________________________

What was the diagnosis and treatment?
_________________________

What is the name and contact information of the medical doctor who gave you this diagnosis and treatment?
_________________________

Assets

What are your assets?
_________________________

Abilities/skills

What are your abilities and skills?
_________________________

Allergies

Are you allergic to anything (medications, foods, latex)?
_________________________

(Yes / No)
If yes, please list:
_________________________

Complaint/problem

Do you have any complaint/problem relevant to human health care today?
_________________________

If you have any complaint/problem relevant to human health care today, what are the details?
_________________________

How are you feeling today?
_________________________

Do you have any problems today?
_________________________

What seems to be the problem?
_________________________

_________________________

_________________________

_________________________

_________________________

Do you have any other problems?
_________________________

Can you explain?
_________________________


Communications

What is the best method to communicate with you?
E-mail.
Fax.
Telephone call.
Postal mail.
Communication through media.
_________________________


Habits

Do you smoke now?
(Yes / No)
How much?
__________________

Have you ever smoked?
(Yes / No)
If yes, for how many years?
________
When did you quit?
_______________

Do you drink alcohol?
(Yes / No)
If yes, how much?
__________________
How often?
___________________

Have you used recreational drugs?
(Yes / No)
If yes, which ones?
_______________________________________________

When was the last time you used one/them?
___________________________

Impairment Rating and Disability Determination
Health status


How would you describe your health status relevant to your age?

_________________________

100% mentally fit.
100% physically fit.

Do you have any problems with activities mentioned below relevant to your age?

Walking
Seeing
Hearing
Speaking
Breathing
Learning
Working
Caring for oneself (eating, dressing, toileting, etc.)
Performing manual tasks
Getting started after sleep
Sitting
Sleeping
_________________________

Last updated

When was the record first created?
_________________________

When was the record last updated?
_________________________

Who created the record?
_________________________

Who updates the record?
_________________________

When were you last seen by a medical doctor?
_________________________

What is the profile and contact information of the medical doctor?
_________________________

Surgical History

Have you ever undergone surgery?
_________________________

(Yes / No)
If yes, please list operations and dates:
_________________________

These are basic questions.
There are many more.
Here are further guidelines.