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Edit Clinical Notes AOHC - Female Preventative Care

i Narrative View n j k l m n j Template View k l m

Vital Signs

c Premature d e f g graph sheet

HT:

graph sheet

WT:

Add BP CM KG

percentile:

Mother's Stature

percentile:

Father's Stature

HT/WT:

percentile:

BMI:

percentile:

Add PEFR CM CM

Status:

BSA: graph sheet

Systolic

graph sheet

CM

WC:

BP:

Diastolic

Limb

graph sheet

HR:

BPM:

Rhythm:

graph sheet

RR:

BPM:

Desc:

graph sheet

T:

graph sheet

SpO2:

graph sheet

PEFR:

graph sheet

BS:

Date

Adult

/

째C

Cuff Size

5

2

2013

^ DD/MM/YYYY

Desc:

Location:

L/min

i pre-bronchodilator n j k l m n j post-bronchodilator k l m

5

2

2013

^

DD/MM/YYYY

mmol/L

i Narrative View n j k l m n j Template View k l m

Lifestyle/Habits Diet:

Fat/Cholesterol:

Fiber:

5

5

5

6

6

6

Calcium:

Sodium:

Family:

5

5

5

6

6

6

Exercise:

Relationships:

5

Smoking:

5

5

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6

6 Alcohol:

Drugs:

Sexual History:

5

5

5

6

6

6

Sleep:

Family Planning/Contraception:

5

5

6

6

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Functional Inquiry

HEENT normal: HEENT:

c d e f g

Sexual Function normal: g c d e f Sexual Function:

5

5

6

6

CVS normal: g c d e f CVS:

Resp normal: Resp:

6

MSK normal:

c d e f g

MSK:

5

5

6

6

c d e f g

Neuro/Falls normal:

c d e f g

Neuro/Falls:

5

5

6

6

Breasts normal: g c d e f Breasts:

Derm normal: Derm:

c d e f g

5

5

6

6

GI normal: f g c d e GI:

Cognition normal: g c d e f Cognition:

5

5

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6

6 GU/Mensus normal: g c d e f

Depression Screen:

GU/Mensus:

Mental Health normal:

5 Mental Health:

c d e f g

Yes No

5 6

6

Constitutional SX normal: g c d e f Other:

Constitutional SX:

5

5

6

6

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Education/Counselling(female):

folic acid (0.4-0.8mg/childbearing women)discussed g c d e f adverse nutritional habits discussed:

c d e f g

dietary advice on fat/cholesterol (30-69 yrs): g c d e f adequate calcium intake (1000-1500 mg/d) discussed

c d e f g

adequate vitamin D intake (400-1000 IU) discussed: g c d e f regular, moderate physical activity discussed: g c d e f avoid sun exposure discussed: g c d e f tanning salon use discussed:

c d e f g

seat belts discussed: g c d e f hearing protection discussed: g c d e f noise control programs discussed:

c d e f g

safe sex practices/STDs/BC discussed: g c d e f physical violence in environment discussed: g c d e f safe firearm storage (if applicable) discussed: g c d e f home hazards discussed: g c d e f smoke detectors in the home discussed: g c d e f regular testing of smoke detectors discussed: g c d e f

For general population unless otherwise stated Obesity (BMI>=30): Yes No

Alcohol: Yes

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weight loss counselling if overweight:

c d e f g

screen for mental illness: g c d e f multidisciplinary approach:

c d e f g

counselling for problem drinking: case

c d e f g

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Yes No

case finding for problem drinking: cognitive assessment (if concerns): g c d e f c d e f g fall assessment (if history of falls): f g c d e

Elderly: Yes No

Smoking: Yes No

smoking cessation discussed: g c d e f

c d e f g

smoking cessation program referral:

dietary advice given: g c d e f

c d e f g

nicotine replacement therapy discussed:

Oral Hygiene: g c d e f

brushing/flossing teeth discussed:

c d e f g

tooth scaling and prophylaxis discussed: g c d e f fluoride (toothpaste/supplement) discussed: f g c d e Parents with Children: Yes No

hot water thermostat (<54째C): g c d e f helmet safety:

c d e f g

non-flammable sleepwear: g c d e f poison control prevention:

c d e f g

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Physical Examination (female) Physical Examination Conducted: Yes No Eyes normal: Eyes:

c d e f g Visual Acuity Snellen Sight Card Done:

c d e f g

5 Right 20\

Right with Glasses\Visual Aids: g c d e f

Left 20\

Left with Glasses\Visual Aids: g c d e f

6 Ears normal:

Hearing Discussed: g c d e f

c d e f g

Ears:

Nose normal:

Left ear:

5

5

6

6

6

c d e f g

Breasts normal: g c d e f Breasts:

Nose:

Mouth/Throat normal:

Right ear:

5

c d e f g

5

5

6

6 Abdomen

c d e f g

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Abdomen normal: Abdomen:

Mouth/Throat normal:

c d e f g Mouth/Throat:

5

c d e f g

5

6

6 Neck/Thyroid normal: g c d e f

Ano-Rectum normal:

Neck/Thyroid:

Ano-Rectum:

c d e f g

5

5

6

6

CVS normal: g c d e f

Pelvic normal: g c d e f

CVS:

Pelvic:

5

5

6

6

Resp normal: g c d e f

Neuro normal: g c d e f Neuro:

Resp:

5

5

6 Derm normal: g c d e f Derm:

5

6 MSK/Joints normal: MSK/Joints:

c d e f g

6 c d e f 5 Extremities normal: g Extremities:

5

6

Diagrams

6

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Breasts:

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Female Body:

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Aohc female preventative care