Health App Case Study: Physician

Manage Patients

Add Patient
Manage Patients
File Manager
Referrals

Required Files
Generic Files
Labs

Referred Out
Referred to Me

Completed

File Name / Description	Status	Received
John Doe Main File here Lorem ipsum dolor sit amet, consectetur adipiscing elit. Duis ex libero, volutpat ac eros non, tincidunt varius magna.	Open	06/15/15
Patient 106540 file data Lorem ipsum dolor sit amet, consectetur adipiscing elit. Duis ex libero, volutpat ac eros non, tincidunt varius magna.	Open	06/15/15
File 1504 Lorem ipsum dolor sit amet, consectetur adipiscing elit. Duis ex libero, volutpat ac eros non, tincidunt varius magna.	Open	06/15/15
File for patient 146506540121 Lorem ipsum dolor sit amet, consectetur adipiscing elit. Duis ex libero, volutpat ac eros non, tincidunt varius magna.	Closed	06/15/15
John Doe medical record data Lorem ipsum dolor sit amet, consectetur adipiscing elit. Duis ex libero, volutpat ac eros non, tincidunt varius magna.	Open	06/15/15

File Name / Description	Insurance	Driver's License	Status	Received
John Doe Main File here Lorem ipsum dolor sit amet, consectetur adipiscing elit. Duis ex libero, volutpat ac eros non, tincidunt varius magna.			Open	06/15/15
Patient 106540 file data Lorem ipsum dolor sit amet, consectetur adipiscing elit. Duis ex libero, volutpat ac eros non, tincidunt varius magna.			Open	06/15/15

Lab Name

Sub Title

Feed data

Lorem ipsum dolor sit amet, consectetur adipiscing elit. Duis ex libero, volutpat ac eros non, tincidunt varius magna. Vivamus pretium nunc at nunc finibus hendrerit. Nam faucibus efficitur ipsum, id suscipit metus. Suspendisse potenti. Suspendisse lacinia lorem id ullamcorper pulvinar.

Lab Name

Sub Title

Feed data

Lab Name

Sub Title

Feed data

Update your information

First Name:

Last Name:

Date of Birth:

Sex:

Male Female

Referring Physician Name:

Phone #:

Primary Care Physician Name:

Phone #:

Update your Contact Information

Street Address:

City:

State:

Zip Code:

Phone #:

Emergency Contact:

Contact's Phone #:

Update your Insurance Information

Provider:

Plan ID:

Card ID:

Pharmacy:

List your Allergies

Allergy:

Known Allergies

List your Shot History

Shot Type:

Shot List

List your Medications (please list all medications and supplements that you are using at this time)

Drug / Supplement:

Dosage:

How many times per day?

Medications List:

Drug / Supplement	Dosage	Use

Family Medical History (please list medical problems of biological family members)

Mother:

Father:

Sister(s):

Brother(s):

Children:

Current Complaint (reason for your visit today):

Nature / Mechanism of injury:

Date of Injury:

HPI (History of Present Illness) Please provide a brief overview of your pain history:

Severity:

Mild Moderate Severe

Duration:

Constant Intermittant

Modifying Factors / Relieved with:

Sitting Standing Lying Walking

Worse with:

Sitting Standing Lying Walking

Associated Symptoms:

Rate your pain by selecting ONE NUMBER that best describes your pain at it's worst:

1 2 3 4 5 6 7 8 9 10

No Pain

Moderate Pain

Extreme Pain

Rate your pain by selecting ONE NUMBER that best describes your pain at it's least:

1 2 3 4 5 6 7 8 9 10

No Pain

Moderate Pain

Extreme Pain

Rate your pain by selecting ONE NUMBER that best describes your pain right now:

1 2 3 4 5 6 7 8 9 10

No Pain

Moderate Pain

Extreme Pain

Review of Symptoms. To your knowledge, do you now have or have you ever had any of the following:

Constitutional:

Fever

Weight Loss

Sweats

Other

Eyes:

Visual Disturbance

Eye Pain

Other

Ears, Nose, Mouth Throat:

Pain	Hearing Loss	Loss of Smell	Difficulty Swallowing
Other

Cardiovascular:

Chest Pain

Palpitations

Other

Respiratory:

Cough	Sputum	Shortness of Breath	Wheezing
Other

Gastrointestinal:

Abdominal Pain	Diarrhea	Constipation	Nausea
Vomiting	Other

Musculoskeletal:

Weakness or Paralysis in Arms or Legs

Pain

Other

Integumentary:

Skin Rashes

Lesions

Ulcers

Other

Neurological:

Headache

Seizure

Dizziness

Other

Psychiatric:

Depression

Anxiety

Psychosis

Other

Endocrine:

Increased Nighttime Urination

Nighttime Thirst

Heat or Cold Intolerance

Other

Hematologic / Lymphatic:

Enlarged Lymph Nodes

Excessive Bleeding

Other

Are you currently pregnant or considering getting pregnant:

Yes No

Past Medical History

Do you currently have, or have you ever had any of the following? (Please check all that apply)

Anesthesia Complications	Asthma	Blood/Bleeding Disorder	Cancer	Cold Hands/Feet
Depression	Diabetes	Emphysema	Epilepsy	Fibromyalgia
Headaches/Migraines	Heart Attack	Heart Failure	Hepatitis	High Blood Pressure
Kidney Disease	Liver Disease	Phlebitis or Blood Clots	Rheumatologic Disease	Seizure
Significant Injuries	Skin Condition	Sleep Apnea	Stroke	Taking Anticoagulants
Thyroid Disorder	Ulcer	Other (specify)

Previous Medications (Check the medications you have used for your current pain problem)

Narcotics:

Demorol	Morphine	Dilaudid	MS Contin
Methadone	Darvocet	Percocet	Vicodin
Tylenol 3	Fentanyl Patch	Oxycontin	Avinza

NSAIDs:

Asprin	Motrin	Ibuprofin	Dolobid
Advil	Naprosyn	Relafen	Mobic
Voltarin	Lodine

Sedatives/Relaxants:

Ativan	Xanax	Valium	Flexeril
Parafon Forte

Sleep Medicine:

Halcion

Ambien

Restoril

Benadryl

Antidepressants:

Elavil	Pamelor	Desipramine	Effexor
Desyrel	Prozac	Zoloft	Paxil
Serzone	Remeron	Cymbalta

Anticonvulsants:

Neurontin	Klonopin	Tegretol	Dilantin
Lyrica	Topamax

Neuropathic Pain Medications:

Baclofen

Phenoxybenzamine

Ultram

Prazosin

Any other not listed:

Have you been treated by any other Pain Specialist or Clinic:

Yes No

If Yes, name of specialist or clinic:

Date last seen:

Previous Treatments

Check all that apply:

Acupuncture	Traction	TENS unit	Chiropractor
Ice / Heat	Physical therapy	Biofeedback
Massage	Psychologist

List your Hospitalizations (surgery, childbirth, medical illness)

Date (approx. year):

Reason:

Place (hospital or city)

Hospitalizations List:

Reason	Place	Date

Thank You for your Information. Please wait until a Doctor can see you.

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