Website Repor t January 2008 - Expanding Your Scope of Practice

The following new- patient, health- review, questionnaire is important for a number of reasons. Every patient
comes to your office with a chief complaint that is affecting their quality of life, enough to make them seek
help. Often it is an obvious spinal condition like back, neck or joint pain. For them it is a simple matter. They
don’t know that early heart conditions cause neck and shoulder pain. They don’t know that gall bladder stones
can cause a nagging pain in the right scapula and lower rib region. There is so much they don’t know, that they
would never mention, when filling in a form asking for their symptoms.

When you study the following questionnair e, you will realize that these few questions, will uncover most of the
disease areas and allow you to direct your consultation questions to specific, suspected, secondary conditions.
These secondary conditions may be very significant causal factors, in the chief complaint. Often, the
questionnaire reveals a condition you can tr eat, that the patient wasn’t aware of came under your scope of
practice.

Make no mistake patients want to be healthy and appreciate your thorough approach and offer to help them with
a condition their previous health care pr ovider failed with.

The more service we can rationally apply, the more patients appr eciate our services. Misdirected doctors feel
they are “selling” their services, instead of having the attitude of providing services that give patients a chance
to heal.

After discussing their problems in the consultation, I explain what the examination needs to look for and why
certain tests need to be ordered. They need to be told that after reviewing all the information, I will be able to
tell them “Whether or not I can help them”. This can be done as soon as all the tests are completed. Usually the
2nd visit as I have x-r ays taken at a r adiologists’ office.

You can copy this questionnair e and start using it. See for yourself if it leads to giving more service to your
patients. Just for fun, get your existing patients to fill it out and see if you missed anything in your initial work-
up.









IT APPEARS BELOW SO THAT IT IS ON A SEPARATE PAGE

HEALTH QUESTIONNAI RE

Patient Name:________________________________________________________________ Date:________________


Yes No Yes No

1. Are you physically active? 22. If yes: Has it increased?

2. Are you troubled with pain in any of 23. Has it decreased?
your joints?
3. If yes, is it worse in the night? 24. Has your weight changed more than 10
Pounds in the last year?
4. Do your joints ever swell?
25. Are you troubled with frequent loos e
5. Do you wake up with stiffn ess or bowel movements?
Ach ing in your join ts or muscles?
26. Are you troubled with constipation?
6. Are you troubled by wakin g in the early
Hours and being unable to go to sleep 27. Have you noticed any bloo d or mucus
again ? in your stoo l?

7. Do you have d ifficulty in go ing to sleep ? 28. Are you troubled with irritation, itching or
burning around th e b ack passage?
8. Do you suffer with backache?
29. Are you troubled with hemorrhoid s?
9. If yes: Is this ever accompanied by pain
down one or both legs? 30. Do you suffer with shortness of breath
on exertion?
10. Is this ever aggravated by cou ghing or
sneezing? 31. Are you troubled by pain or tightness in
your chest on ex ertion?
11. Do you get neck pain?
32. If yes: Is it relieved by resting?
12. Does it radiate to should er, arm or hand?
33. Do you suffer with a cramp-like pain in
13. Do you get any numbness or ting ling in either leg when walk ing
your arms, han ds, legs or feet?
34. If yes: Do you have to s top or s low down
14. Do you ex perience any abnormal noises to relieve it?
in your ears or h ead?
35. Are you subject to blackou t, dizzy spells,
15. Are you often troubled by headaches? or fainting?

16. If yes: Are they throbbing and accompanied 36. Are you troubled with a frequent or
by sickn ess or nausea? persisten t cough?

17. Are you troubled by pain or ach ing in your 37. If yes: Is there a lo t of p hlegm?
sto mach?
38. Do you have any pain or difficu lty
18. If yes: Is it relieved by eating? during urinatio n?

19. Is it relieved by drinking milk ? 39. Is urination more frequent lately?

20. Does it often wake you at night? 40. Have you any lu mps, cysts, or unusual
Swelling anywhere on your body?
21. Have you had any persistent change in your
appetite during the las t th ree months? 41. Have you visited a sub-tropical or
tropical country in the last year?

42. Are you easily d epressed?


WOMEN’S QUESTIONNAIRE


43. How many d ays is it s ince the first date of
your last menstrual period? ____ ___________

YES NO

44. Are your periods: Regular?

45. Slightly irregular?

46. Very irregular?

47. Have the ceased?

48. Are you taking a contraceptive pill, or
wearing a contraceptive patch ?

49. Are you on contraceptive in jections?

50. Are your wearing an intrauterine contraceptive
device?

51. Are your periods accompanied by lower abdominal
pain or d isco mfort?

52. If yes: Is the pain of moderate severity?

53. Is it severe (do yo u take a pain reliever)?

54. Is it severe and incapacitatin g (do you n eed
to go to bed)?

55. Do you notice bleeding in between period s?

56. If your periods have stopped completely, hav e
You since h ad any b leeding from the front passage?

57. Have you experienced any recent vaginal discharge?

58. Have you given birth?
If yes, what ages: _______ ____________________

59. Have you had any gynecological or abdominal
surgerys?

60. Do you ex perience incontinence during straining,
coughing, sneezing or laug hing?

61. Do you have d isco mfort on, or frequen t urination?

62. Have you ever b een treated for a urinary tract infection?

63. Have you a lump in either breast?