ࡱ> ~ Tbjbj 4vee 6[8,D4ppppp$ z#`Q'ppNpp@p<-}d0#*##(0"/%v# :   Womens Clinic Examination Chief Complaint: ( Here for breast examination and counseling. ( Here for osteoporosis screening and counseling. ( Additional question(s) or concern(s): _____________________________________________________________________________________ _____________________________________________________________________________________ ( Old chart not available  History: Osteoporosis RiskYesNoPostmenopausalHRT> 3 mo. hx (ever) of anti-coagulant, steroid, or anti-seizure medicationHyperparathyroidism* Chronic disease such as dementia, gastric surgery, hemiparesis, Parkinsons, vertigo, blindness, rheumatoid arthritis* Hx low-trauma Fx* Hx in 1st degree relative* Alcohol abuse* Smoker* Physical inactivity* Low weight* Inadequate sunlight exposure or low dietary calcium  Medications: % Medication list reviewed; no changes % Medication list reviewed and updated Health Maintenance: Last mammogram ____/____/____ Last clinical breast exam ____/____/____ Last occult blood ____/____/____ Last Osteoporosis screening ____/____/____ (Must be 23 months for Medicare reimb.) Physical Exam: Vital Signs: Weight: ______ lbs. Blood Pressure: __________ Temp_______________ Examination of Breasts: NoYesComments: %No significant clinical findingsBreast ImplantsMastectomyDistinct palpable mass or thickeningSkin dimpling/reddeningBloody nipple dischargeNipple discharge that is unilateral, spontaneous or localized to one ductSkin retraction or scaliness around nippleInverted nipple (recent occurrence/onset) in a woman who is not lactatingNew onset of pain in elderly atrophic breast Impression:  Plan: Recommend osteoporosis screening %Yes %No Recommend Vitamin D (600 IU/d) and Calcium (1000 mg/d) supplement %Yes %No Screening Mammogram needed %Yes %No Diagnostic Mammogram needed %Yes %No Specialty referral given: %Yes %No  to which specialty ______________________________ Occult blood  home        E G ` a r s y z { W X [ n o p r ƽ}}}t}}ƽ}ƽ}ƽ}h.>*CJaJh.CJaJ h.aJjh.Ujh.CJUaJ jh.CJaJh.CJaJh.5>*CJaJh.5CJaJh.&jh.CJOJQJUmHnHuh.CJ OJQJaJ h.CJOJQJaJh.CJOJQJ+C  }xsq}ql}$@&$a$$a$Vkd$$Ifl0+-$ 6Pi-,4 la V< $i&P#$/If !$i&P#$/If   F G Y ] ` a p q r ^kdf$$IflF \ ,  t06    44 la $$Ifa$$If r s w x y qkkk$Ifkd$$IflF \ ,  t06    44 lay z qkkk$Ifkd$$IflF \ ,  t06    44 la qkkk$Ifkd$$IflF \ ,  t06    44 la U V W qkkk$Ifkd$$IflF \ ,  t06    44 laW X l m n qkkk$Ifkd6$$IflF \ ,  t06    44 lan o qkkk$Ifkd$$IflF \ ,  t06    44 lar t y { * , . 0 H L  0 YmFTlnr~LNNNOO$O(O.O2O6O>尿᰿԰谿ٰϲ𨤨MM.䴳.>*䴳..5>*䴳.5C..䴳*.䴳ڝ䴳< qkkk$IfkdV$$IflF \ ,  t06    44 la qkkk$Ifkd$$IflF \ ,  t06    44 la qkkk$Ifkdv$$IflF \ ,  t06    44 la qkkk$Ifkd$$IflF \ ,  t06    44 la & ( * qkkk$Ifkd$$IflF \ ,  t06    44 la* , . 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