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--- ummc:va:cprs_templates [2023/12/18 14:47] – admin
+++ ummc:va:cprs_templates [2023/12/18 14:51] (current) – [Clinic Note] admin
@@ Line 36: / Line 36: @@
 -
+Environmental exposures:
+[ ] oil diffusers/scented candles/glade/Airwick plugins/incense sticks/ oil in humidifiers
+[ ] hot tub use
+[ ] pets/ birds at home
+[ ] playing any wind instruments
+[ ] hobbies such as wood working
+[ ] mold/water damage in the house
+Military-specific exposures:
+[ ] Agent orange - Vietnam War
+[ ] Depleted Uranium - Gulf War
+[ ] Asbestos - Navy due to shipyards
+[ ] Mustard gas – WWI
+[ ] Particulate matter
+[ ] Burn pit
+[ ] Chromium
+Occupational exposures outside the military :
+[ ] Asbestos - construction workers, elictricians, mining, railroad, fire fighters
+[ ] Ionizing radiation - uranium mining
+[ ] Vinyl chloride - pulp & paper workers
+[ ] Arsenic - smelting of ores, pesticide application, wood preservation
+[ ] Beryllium - ceramic workers, missile technicians, nuclear reactor workers, jewelers
+[ ] chromium - stainless steel production, welding, tanning industries
+[ ] Nickel - battery makers, ceramic makers, electroplaters, glass workers, jewelers, metal workers & welders, painters
+PMH:
+|ACTIVE PROBLEMS|
+Medications:
+|ACTIVE MEDICATIONS|
+Allergies:
+|ALLERGIES/ADR|
+|999Y1 PNEUMO|
+|999Y1 FLU,WHOLE|
+SH:
+Functional status: @@
+[ ] fully independent in ADLs and IADLs
+[ ] uses cane at baseline
+[ ] uses walker at baseline
+[ ] uses wheelchair at baseline
+[ ] uses oxygen at baseline
+[ ] Tobacco Smoking –
+Age of onset of smoking: years
+Duration of smoking: years
+Maximum packs/day:
+Current cigarettes /day:
+Any alternate tobacco product
+[ ] cigar,
+[ ] pipe,
+[ ] waterpipe
+[ ] Vape/e cigarettes
+[ ] Second hand smoking
+[ ] Indoor emission from household combustion
+[ ] Outdoor air pollution

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