NURSING C350 New Patient Questionnaire

Comprehensive Physical Examination

Medical Questionnaire

Snippets from the Paper:
Head:

  1. Do you suffer from headaches?  Yes  No
    If so, have they been “labeled”( i.e. migraines, tension, cluster, etc.)  Yes  No
  2. Is your hearing compromised?  Yes  No
    If “yes”, is there a past history of acoustic trauma, ear disease, or family history of a hearing deficit?
  3. Have there been any changes in your vision in the past 1-2 years?  Yes  No
  4. Have you ever noted transient changes in your visual fields? (i.e. “blind spots”) If so, in which eye and for how long?  Yes  No
  5. Have you had an eye examination within the past two years?  Yes  No
  6. Do you have a history of allergic symptoms? (sniffling, nasal congestion, etc.)  Yes  No
  7. Do you have a history of hoarseness, or other recurrent abnormalities of voice?  Yes  No

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