-wear lab coat -less than 15min -Scan the room -show ID *NO notes, the patient must answer questions Name: Amber Age & DOB, Sex, Race, Marital Status 39 April 12th, 1980, Female, Caucasian, Single CC-and in your own words what is the reason you are coming in today? “I have been having a lot of headaches lately.” O-onset- “When did the headaches start? Does the HA come right away or gradually get worse?” L-location-“Where does it hurt the most?” D-duration-“And how long do they last?” C-character-“Are they pounding, sharp, pressure like? A-aggravating/associated factors-“Do you get n&v, photophobia, lack of caffeine? R-relieving factors-“Excedrin helps but it doesn’t go away, caffeine, drinking water” T- treatments previously tried – response? Why discontinued? “I was getting acupuncture but it did help after 5 treatments” S-severity-8/10 where I need to call off work
Medications “Do you take any medications or otc vitamin?” General Health: Any illnesses, diseases, emotional/psych hx?
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- Summer '15