Medical Symptom Checklist

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Medical Symptom Checklist

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BasicMed Comprehensive Medical Examination Checklist – Federal …

SECTION 3 of this checklist. The physician completes the “Physician's Signature
and Declaration” if the physician determines that he/she is not aware of any
medical condition that, as presently treated, could interfere with the individual's
ability to safely operate an aircraft. 3. The completed checklist shall be retained in
the …


problems. Rate each one on a scale of 0 to 4 according to how much of a
problem that item is for you. A rating of zero would mean that the item is not a
problem for you; one, a slight problem; two, a moderate problem; three, a serious
problem; …

Acute Concussion Evaluation – Centers for Disease Control and …

6. EARLY SIGNS: __Appears dazed or stunned __Is confused about events __
Answers questions slowly __Repeats Questions __Forgetful (recent info). 7.
Seizures: Were seizures observed? No__ Yes___ Detail. _____. B. Symptom
Check List* Since the injury, has the person experienced any of these symptoms
any more …

NHSC COmprehensive Behavioral Health Services Checklist

management, chronic disease management, and Substance Use Disorder
Treatment): Broad range of evidence-based or promising behavioral health
practice(s) with the primary goal of reducing or ameliorating behavioral health
symptoms, improve functioning, and restore/maintain a patient's health (e.g.,
individual, family, …

PHQ-9 Nine Symptom Checklist

Over the last 2 weeks, how often have you been bothered by any of the following
problems? Read each item carefully, and circle your response. a. Little interest or
pleasure in doing things. Not at all. Several days. More than half the days. Nearly
every day b. Feeling down, depressed, or hopeless. Not at all. Several days.

Detailed emergency Medical Services (EMS) checklist for Ebola …

This checklist is intended to enhance collective preparedness and response by
highlighting key areas for EMS personnel to review in preparation for
encountering and providing medical care to a person with … Africa may travel to
the U.S., develop signs or symptoms of Ebola , and seek medical care from EMS

Checklist for Adverse Effects, Function, and Opioid Dependence

Activities within the house and outside (e.g., household chores, shopping, etc.) •
Activities at work (return to work, modified duties, trial employment, etc.) Checklist
for signs of opioid dependence. • On high and escalating doses of opioids. •
Frequently runs out of medicine early observed to be intoxicated or in withdrawal.

verification checklist – Delaware Health and Social Services

Office of Medical Marijuana. For the most current information regarding this
application, medical marijuana laws in the State of Delaware, and more see the
official website:
Date Faxed.

Common Functional Limitations Checklist – Wisconsin Department of …

Common Functional Limitations Checklist. Designed to facilitate discussion and
identification of limitations following a medical diagnosis. Compiled by Sara
Sharpe M.S.; C.R.C. with assistance from Deb Henderson-Guenther M.S.; C.R.C..
Adapted from the Disability Handbook, Department of Rehabilitation Education &

Michigan Medical Marihuana Program Instructions Checklist

Michigan Medical Marihuana Program. P.O. Box 30083. Lansing, MI 48909.
Checklist. Application Form for Registry Identification Card. ▫ Any use of white-out
on or alterations to the …. have completed a full assessment of the patient's
medical history and current medical condition, including a relevant, in-person,

Client Assessment – California Department of Health Care Services

Spiritual activities: □ Other: Comments: Presenting Problems/Target Symptoms:
Use client's/caregiver's words when possible. 3 …. that present a risk to the child
or others identified in the “Symptom Checklist”. 5 …. Are there any health
concerns (medical illness, medical symptoms)?. □ Unknown/None Reported. □

tool kit for the management of adult anxiety – ahcccs

May 1, 2011 The list of medications universally available through AHCCCS Health Plans and
the. RBHA. Clinical resources and … substance use and whether the anxiety is
better accounted for by another mental disorder. A) Anxiety disorder due to a
general medical condition. B) Alcohol-induced anxiety disorder or.

Protracted Withdrawal – SAMHSA Store

Jul 2, 2010 protracted withdrawal signs and symptoms, and offers suggestions on how to
help clients manage protracted withdrawal in recovery. What is acute withdrawal
? Acute withdrawal is usually referred to simply as. “withdrawal.” The American
Society of Addiction. Medicine defines withdrawal as “the onset of a.

Next Steps After Your Diagnosis Finding Information and Support

inside back cover for a list of AHRQ's consumer publications. … Every person is
different, of course, and every person's disease or conditiondisease or
condition. And it has tips to help you learn more about your specific problem and
how it can be treated. The information in this booklet is presented in a simple way
to help …

Guidelines for Identifying and Educating Students with Emotional …

Checklist for Comprehensive Evaluation . … Checklist for Ongoing Assessment of
Student Performance/Progress Monitoring . …… medical condition. Examples of
typical characteristics associated with depression or unhappiness include but are
not limited to: • depressed or irritable mood most of the time (e.g., feeling sad, …

Know Your Rights: Students with ADHD – U.S. Department of …

evaluation if you suspect a student has ADHD, or a student has received a
diagnosis of ADHD outside of school. … If your school district requires, as part of
the evaluation, a medical assessment to determine whether a student … http://, and
visit OCR's.

Quick Guide to Health Literacy – Office of Disease Prevention and …

The final section contains a list of resources, including. Web sites … health topics.
People with limited health literacy often lack knowledge or have misinformation
about the body as well as the nature and causes of disease. Without … adults
may lack the skills needed to manage their health and prevent disease. Fourteen

Form I-693 – USCIS

altered information or documents with regard to my medical examination, I
understand that any immigration benefit I derived from this medical examination
may be …. Remarks: (Include any signs or symptoms of TB, additional tests and
therapy given, with start and stop dates and any changes. If you did not perform
TST or …