Flint Medical Chart Abstraction

Form Approved

OMB No. 0923-0051

Exp. Date 03/31/2018

Flint Medical Chart Abstraction Form

Reviewer Name: ________________________ Date of Review: ___ / ___ / ____ Data entered: ___ / ___ / ____

Facility: ___________________________________________ ID: _________

Patient Name: ___________________________________________ Patient Phone Number_____________

Address: Street: ___________________________ City: ___________________ State: _____ Zip: _____________

Patient Demographics

DOB: ____ / ____ / _______ Sex: □ Male □ Female □ N/A Occupation: ____________________________________

^{MM DD YYYY} Ethnicity: □ Hispanic □ Not Hispanic

Insurance: Race: (check all that apply)

□ Private □ Medicare/Medicaid/Government program □ American Indian/ Alaskan Native □ Asian □ Black

□ None □ N/A □ Other: ___________________ □ Native Hawaiian/ Pacific Islander □ White

Visit Information

Date of Visit: ____ / ____ / ______ Time of arrival: ____:____ □ am □ pm

^{MM DD YYYY}

Chief Complaint: ___________________________________________________________________________________

Initial Vital Signs: Height: _________ □ cm □ in Weight: ________ □ kg □ lb

Temp (°F): ________ Heart Rate: _______ Respiratory Rate: _______ BP (mmHg): ______ / _______

Current Signs and Symptoms (check all that apply)

Location Onset Date End Date Size(in)

□ Rash □ Face □ Arms □ Legs □ Feet □ Neck □ Other_____ __/__/___ __/__/___ _____

□ Hives □ Face □ Arms □ Legs □ Feet □ Neck □ Other_____ __/__/___ __/__/___ _____

□ Raised bumps □ Face □ Arms □ Legs □ Feet □ Neck □ Other_____ __/__/___ __/__/___ _____

□ Itchy Skin □ Face □ Arms □ Legs □ Feet □ Neck □ Other_____ __/__/___ __/__/___ _____

□ Painful Skin □ Face □ Arms □ Legs □ Feet □ Neck □ Other_____ __/__/___ __/__/___ _____

□ Eczema □ Face □ Arms □ Legs □ Feet □ Neck □ Other_____ __/__/___ __/__/___ _____

□ Psoriasis □ Face □ Arms □ Legs □ Feet □ Neck □ Other_____ __/__/___ __/__/___ _____

□ Erythema/Redness □ Face □ Arms □ Legs □ Feet □ Neck □ Other_____ __/__/___ __/__/___ _____

□ Numbness/Tingling □ Face □ Arms □ Legs □ Feet □ Neck □ Other_____ __/__/___ __/__/___

□ Hair Loss/Alopecia Description: _________ Location: ___________ __/__/___ __/__/___

(e.g. patchy, strands, etc) (e.g. right side, crown, hairline etc)

□ Tooth loss Quantity: ___________ Location: ___________ __/__/___ __/__/___

□ Fever __/__/___ __/__/___

□ Diarrhea __/__/___ __/__/___

□ Eye Irritation __/__/___ __/__/___

Notes/other symptoms: _________________________________________________________________________

Medical History (check all that apply)

□ Asthma □ Congestive heart failure Current Medications:

□ Shortness of Breath □ COPD _____________________________________

□ Pregnant □ Breastfeeding □ Depression _____________________________________

□ Wheezing □ Stress Screening: __________ Medications Prescribed as a Result of Visit:

□ Diabetes □ Tobacco use: _________________ ____________________________________

□ Allergies: __________ □ Other: ______________________ _____________________________________

□ Hypertension _______________________

Public reporting burden of this collection of information is estimated to average 15 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS E-11 Atlanta, Georgia 30333; ATTN: PRA (0923-0051)

Skin History (check all that apply)

Location Onset Date End Date Size(in)

□ Rash □ Face □ Arms □ Legs □ Feet □ Neck □ Other_____ __/__/___ __/__/___ _____

□ Hives □ Face □ Arms □ Legs □ Feet □ Neck □ Other_____ __/__/___ __/__/___ _____

□ Raised bumps □ Face □ Arms □ Legs □ Feet □ Neck □ Other_____ __/__/___ __/__/___ _____

□ Itchy Skin □ Face □ Arms □ Legs □ Feet □ Neck □ Other_____ __/__/___ __/__/___ _____

□ Painful Skin □ Face □ Arms □ Legs □ Feet □ Neck □ Other_____ __/__/___ __/__/___ _____

□ Eczema □ Face □ Arms □ Legs □ Feet □ Neck □ Other_____ __/__/___ __/__/___ _____

□ Psoriasis □ Face □ Arms □ Legs □ Feet □ Neck □ Other_____ __/__/___ __/__/___ _____

□ Erythema/Redness □ Face □ Arms □ Legs □ Feet □ Neck □ Other_____ __/__/___ __/__/___ _____

□ Numbness/Tingling □ Face □ Arms □ Legs □ Feet □ Neck □ Other_____ __/__/___ __/__/___

□ Hair Loss/Alopecia Quantity: _______ Location: _________ __/__/___ __/__/___

Notes/other skin history: _________________________________________________________________________

______________________________________________________________________________________________

Diagnosis/Treatment/Recommendations

Diagnosis: _____________________________________________________________________________________

Treatment/Recommendations: ______________________________________________________________________________________________

______________________________________________________________________________________________

______________________________________________________________________________________________

______________________________________________________________________________________________