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