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Patients Name: __________________ BP: ____________ HR: _________ RR: ___________ Temp: ___________

C.C. ________________________________________________________________________________
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HPI: Transition Question Review of systems (ROS):
This is a check list, do NOT write anything
PAIN NO PAIN Adults Pediatrics
LIQOPRAAA DOC PA FAA THEN FR CS FEVER CUD SAD
PUB SAW ID
Location Describe what happened?
Intensity Onset Trauma/Travel recently Fever
Quality Constant/intermittent Headache Ear pulling
Onset (duration & Frequency) Edema Vomiting (onset, color, frequency)
Precipitating event Precipitating event Nausea/Vomiting (onset, color, Eyes / Ear discharge
Progression Progression frequency) Rash / Rhinorrhea
Previous episodes Previous episodes
Radiation Alleviating factors Fever/chills/Night sweat/Fatigue Cry / Chest symptoms/Cold (recent
Alleviating Racing of / Rash URI, runny nose, cough, chest pain, SOB,
Aggravating Frequency difficulty swallowing)
Associated symptoms Aggravating factors Chest pain/Cough (sputum, odor, color, Urination (increase or decrease,
blood) #dippers, odor, color, dysuria)
Associated symptoms
SOB Diarrhea (onset, frequency, color, blood,
mucus)
Pain in joints
Urinary problem Sleep/ Seizure (loss of bowel or urine,
Bowel problem (abdominal pain, loss of consciousness)
Diarrhea, Constipation, onset, color, blood, Activity (awake, playful, how does he
frequency) looks?)
Dehydration (dry mouth, shrunken
Sleep problem eyes, soft or shrunken spots over the
Appetite head fontanelles)
Weight (how much? Time? Intentional?)

Infection (recent infection)


tiona lQ
Transi
Dizziness (if yes, Vision problem?)

PMH: DDx:
Adults
PAM HITS FOSS
Pediatrics
PAM IF BIG DEALS 1.
Past Medial History
Allergies
Past Medial Hx,
Past Surgical Hx 2.
Medication Previous hospitalization

Hospitalization in the past


Prenatal Hx 3.
Allergies
Ill contacts Medications
Trauma
Surgery Ill contacts
TQ Family Hx

Family Hx Birth Hx Diagnostic work-up


OB/GYN (LMP RTV CS PAP) Immunization
LMP, Menarche, Period lasts? Regularity?
Tampons (# per day), Vaginal discharge,
Growth & Development
Itching, Dryness, Cramps, Spotting?
(Intermenstrual / Post coital), Pregnancy (#
of times? Complication),
Day care (Sick contacts?)
Eating habits

Appetite
Abortion/Miscarriage
Pap Smear (Last pap? Abnormal?), Last Check up (was it normal?)
Sexual Hx (with who? # of partners?
Men or women? Protection? # of partners

since last year?)
Social Hx (WHARTED)
- Work

- Home
- Alcohol (ask CAGE)
- Recreational drugs (Name? Last
time used, method of use?)
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- Tobacco (#pack per day, Educate) ! !
- Exercise
- Diet Visit www.medical-institution.com for USMLE Step 2 CS
Mnemonics & Physical Examination videos
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