North Springs Psychiatry LLC
Amanda J. Batterbee, PMHNP-BC
1880 Office Club Pointe
Suite #1200
Colorado Springs, Colorado 80920
Phone: (719) 272-8222
Fax: (719) 272-8223
Patient Questionnaire
REVIEW OF SYSTEMS QUESTIONNAIRE
Patient Name:
Date: __________________
What do you most want to discuss today?
__________________________________________
Please circle
GENERAL
Fatigue
Decreased appetite
Fevers
Weight loss
Weight gain
Insomnia
Do you have a living will
Do you smoke
Do you drink alcohol
Are you in pain 1-10
EYES, EARS, NOSE and
THROAT
Visual changes
Hearing loss
Sore throat
Nasal Congestion
Yes
Runny nose
Ear Pain
NECK
Swollen Glands
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
RESPIRATORY
Shortness of breath
Cough
Wheezing
Yes
Yes
Yes
CARDIOVASCULAR
Chest pain
Palpitations
High blood pressure
Stroke
Yes
Yes
Yes
Yes
DIABETES
A1C Results
Blood Sugars
CGM – Sensor Problems
CGM – Sensor Readings
Digestion problems
Labs
Lipids
Loss of consciousness
Medications
Meter Problems
Meter Readings
Pump Problems
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
ROS QUESTIONNAIRE WITH VITALS 01/27/2011
Pump Settings
Yes
Sores on feet
Yes
Tingling/numbness –Feet
Yes
GASTROINTESTINAL
Abdominal pain
Constipation
Bloody stool
Diarrhea
Heartburn
Nausea/Vomiting
Yes
GENITOURINARY
Change in bowel habits
Painful urination
Yes
Bloody urine
Increased urination
Leaking Urine
Erectile Dysfunction
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
GYNECOLOGIC
Irregular Menses
Abn. Vaginal Discharge
Pelvic Pain
Pain with intercourse
Painful Menses
Pregnant
Yes
SKIN
Rashes
Itching
Mole Changes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
MUSCULOSKELETAL
Joint pain
Yes Where?
Muscle pain Yes Where?
Leg swelling Yes Where?
NEUROLOGIC
Headaches
Dizziness
Difficulty walking
Numbness or tingling
Yes
Yes
Yes
Yes
PSYCHIATRIC
Anxiety
Yes
Irritability
Yes
Sexual Problems
Yes
Suicidal Ideation
Yes
Depression
Yes
Concerns about your
Yes
emotional or physical safety?
ROS QUESTIONNAIRE WITH VITALS 01/27/2011
ROS QUESTIONNAIRE WITH VITALS 01/27/2011