1. Item number ____
____ Name of condition
For allergy ask:
2. How does this allergy affect --?
For impairment or ulcer, ask:
3. What part of the body is affected by (Condition)?
Show the following detail:
Head (skull, scalp, face)
Back, spine, vertebrae (upper, middle, lower)
Side (left or right)
Ear (inner or outer; left, right, or both)
Eye (left, right, or both)
Arm (shoulder, upper, elbow, lower, or wrist; left, right or both)
Hand (entire hand, or fingers only; left, right, or both)
Leg (hip, upper, knee, lower, or ankle; left, right, or both)
Foot (entire foot, arch, or toes only; left, right, or both)