Quality of Life Assistant
Body System Assessment
| Vital Signs | Blood pressure sitting standing lying |
| Heart rate (pulse) regular irregular | |
| Respiratory rate (breaths per minute) Temperature | |
| Neuro History: | Headache (Y/N) |
| Type: migraine cluster tension | |
| Frequency Duration | |
| Symptoms | |
| Precipitating events | |
| Treatment | |
| Ptosis (droopy eyelid) (Y/N) | |
| Specify | |
| Difficulty focusing (Y/N) | |
| Specify | |
| Cardio–vascular accident – CVA/stroke (Y/N) type | |
| Transient Ischemic Attack – TIA (Y/N) | |
| Syncopal Episode – fainting (Y/N) | |
| Frequency Duration | |
| Symptoms | |
| Precipitating events | |
| Treatment | |
| Residual Effects | |
| Other (specify) |