Pain And Nutrition Subjective Data

(No patient names or initials allowed).

Submit using Word, with a .doc or .dox suffix; do not use .odt because the forms cannot be graded in that format—this goes for the assignments in all the upcoming weeks for this class.

NOTE: YOU MAY NOT USE A PATIENT FROM YOUR WORKPLACE FOR THIS ASSESSMENT. WE DO NOT WANT YOU TO VIOLATE HIPAA!

QuestionsFindings
Current Status
1. Allergies
2. Present health concerns
3. Current medications (prescribed and over-the-counter)
4. Immunizations
Past History
5. Medical
6. Surgical
7. Hospitalizations
8. Injuries
Family History
9. List family medical concerns for 3 generations
Pain(Everyone has had pain at some time or other-if your patient is healthy and currently pain-free, you may need to use a past instance of pain.)
10. Pain (using COLDSPA)

Character: how does it feel—what sort of pain is it?

11. Onset:
12. Location:
13. Duration:
14. Severity (scale of 1 – 10):
15. Pattern—what makes it better or worse:
16. Associated factors—does it cause you to have other symptoms too?
18. How does pain impact the other areas of life?2. What are your concerns about the pain’s effect on

a. general activity?

b. mood/emotions?

c. concentration?

d. physical ability?

e. work?

f. relations with other people?

g. sleep?

h. appetite?

i. enjoyment of life?

Lifestyle and Health Practices
What types of recreation or physical exercise?
Duration of exercise periods, how many times per week?
Stress: Rate overall life stress on a scale of 1 – 10 (1 being least, 10 most). What are the greatest sources of stress?
Methods of coping with stress?
Use of tobacco, alcohol, recreational drugs
Sleep—typical hours per night