EXHIBIT 1.2
Sample History Form
Client: Personal, Social, and Family Information
Name
DOB
I. Today's date
3. Gender: M or F
2. Age
Is your answer to question number 3 based on a transgender sexual change?
If no sexual change has taken place, skip questions 4 and 5.
4. Date of procedure
Medications prescribed
Sexual orientation: heterosexual
Proficient in speaking English YES
Proficient in reading English YES
Ability to read lips YES NO
Preferred spoken language
5. Type of procedure
other
NO
NO
Most comfortable language when speaking
Most comfortable language when reading
Preferred greeting Mr. Mrs. Ms.
gaynesbian
First name
Most comfortable language when speaking
Most comfortable language when reading
Preferred greeting Mr. Mrs. Ms.
Type of nonverbal communication used
Eye contact
Need of interpreter
Relation to interpreter
Quiet/use of silence
Use and definition of time
First name
Use of any common signs (okay, pain, clapping)
Use of comfort space
Tactile use
Use of cultural jargon or slang that may affect evaluation
Perception of pain
Culture
Family role and function
Work
Leisure activities
Frien
Cou
Copyfish
Coun
Ethnicity
Country of origin
Country of birth
Years in United States
Did you grow up in a city
Ethnicity
Major support group
town
suburb
Dominant members of the family
Decision makers for the family
Previous work history
Present work history
Education
Describe importance of religion
Religious beliefs/practices
Religious association
Cultural/religious practices/restrictions
Meaning and use of religious symbols
Interaction with family/significant other—describe
Role of father
Role of elder sibling/siblings
Gran
rural
Role of mother
Sample History Form
Client: Personal, Social, and Family Information
Name
DOB
I. Today's date
3. Gender: M or F
2. Age
Is your answer to question number 3 based on a transgender sexual change?
If no sexual change has taken place, skip questions 4 and 5.
4. Date of procedure
Medications prescribed
Sexual orientation: heterosexual
Proficient in speaking English YES
Proficient in reading English YES
Ability to read lips YES NO
Preferred spoken language
5. Type of procedure
other
NO
NO
Most comfortable language when speaking
Most comfortable language when reading
Preferred greeting Mr. Mrs. Ms.
gaynesbian
First name
Most comfortable language when speaking
Most comfortable language when reading
Preferred greeting Mr. Mrs. Ms.
Type of nonverbal communication used
Eye contact
Need of interpreter
Relation to interpreter
Quiet/use of silence
Use and definition of time
First name
Use of any common signs (okay, pain, clapping)
Use of comfort space
Tactile use
Use of cultural jargon or slang that may affect evaluation
Perception of pain
Culture
Family role and function
Work
Leisure activities
Frien
Cou
Copyfish
Coun
Ethnicity
Country of origin
Country of birth
Years in United States
Did you grow up in a city
Ethnicity
Major support group
town
suburb
Dominant members of the family
Decision makers for the family
Previous work history
Present work history
Education
Describe importance of religion
Religious beliefs/practices
Religious association
Cultural/religious practices/restrictions
Meaning and use of religious symbols
Interaction with family/significant other—describe
Role of father
Role of elder sibling/siblings
Gran
rural
Role of mother
Expectation from this visit
Food preferences
Beliefs on health promotion
Family history
Skin color/hair structure
Reason for Visit
Chief complaint
Perceived cause
Reasons for cause
Symptoms Of illness
Onset and severity (pain scale)
Effects of illness on activities of daily living (ADLs)
Fear Of the unknown about illness
Treatment expectations and results
Beliefs/practices about illness
Health promotion beliefs and practice
Copyfish
ypes of
Client's
Health promotion beliefs and practice
Types of healing practices
Client's appearance
Common diseases and disorders
Beliefs and practices regarding traumatic events
Beliefs and practices for preventive health
Surgical history
Other medical history
Any additional information that may improve client care
Source: American Academy of Family Physicians, American Academy of Pediatrics, American College of Sports Medicine, American Medical Society for
Sports Medicine (2010). Copyright 0 2010 American Academy of Pediatrics. Reproduced with permission.
No comments:
Post a Comment