Chief complaint
(What brings you here today? Major concerns? Key questions/agenda/goals for appt?)
HPI
Symptoms
! Onset
! Palliation/Provocation
! Quality
! Radiation/location
! Severity
! Timeline (change)
! Experienced before
Associated Symptoms
Impact of symptoms
Acute? Chronic adaptation?
Functional impact
Explanatory model
What causing? What worried
about? Expectations of care?
PMH
! Major illnesses
! Hospitalizations
! Surgeries
! Serious Injuries
! Psych
(DM, MI, BP, !chol,
depression, HIV, hernia,
hysterectomy, chole)
Mother
EtOH (CAGE) Drugs Financial
Siblings
Employment ! Living sit.
! Relationships
Children ! Support
! Religious
Review of Systems
General/skin/sleep Respiratory Musculoskeletal Endocrine
! " weight ! Cough Blood? ! Joint pain/back ache ! Heat/cold intolerance
! Fatigue ! Dyspnea Sputum? ! Swelling ! Polydypsia
! Weakness ! Wheezing - Color? ! AM stiffness ! Polyphagia
! Fevers ! Asthma - Quantity? ! Arthritis ! Diaphoresis
! Chills ! Bronchitis ! Gout ! Thyroid problems
! Rash/itching/dryness ! Emphysema ! Cramps ! Diabetes
! " hair ! Pneumonia ! Prox. weakness ! Skin color change
! " nails ! TB ! Functional limit ! Excess hair growth
HEENT Cardiovascular Neuro/psych
! Eyes: o Vision ! High/low BP ! Headache
o Pain ! Murmurs ! Fainting
o Redness ! Orthopnea ! Blackouts
o Tearing ! Nocturnal dyspnea ! Seizures
o Double vision ! Edema ! Paralysis
! Chestpain ! Numbness/tingling
! Ears: o Hearing ! Palpitations (rapid/skip) ! Vertigo/dizziness/difficulty walking
o Tinnitus
! Claudication ! Confusion
o Vertigo
! Varicoseveins ! Memory loss
o Earache
o Discharge ! Thrmbophlebitis ! Tremor/coordination
! Easy bruise/bleed ! Anxiety/tension/stress
o Colds ! Anemia ! Depression/tearfulness
! Nose:
o Stuffiness ! Transfusions ! Suicide attempts
o Hay fever GI GU Genital/sexual Gynecological
o Nosebleed ! " appetite ! Dysuria ! Discharge ! Menarche age _____
o Sinus ! Heartburn ! Nocturia ! Itching ! Irregular period
o Anosmia ! Nausea ! Polyuria ! Sores ! Period freq _______
! Vomiting ! Hematuria ! STD ! Period duration ____
! Mouth: o Teeth ! Abd. Pain ! Urgency ! Hernias ! Bleed between
o Bleeding gums ! Bloating ! Hesitancy ! Test/vag pain ! Last period _______
o Sore throat ! Lactose intol. ! Incontinence ! Testicular mass ! Menopauseage ____
o Horseness
! Diarrhea ! UTI ! Interest ! Symptoms
! Constipation ! Stones ! Function ! Post-men bleed
! Throat: o Dysphagia ! Gas ! " stream ! Satisfaction ! Breast lumps
o Lumps
o Goiter ! Hemmorrhoids/rectal bleed ! Problems ! Breast pain
o Pain ! Liver/gallbladder ! Breast discharge
o Stiffness ! Jaundice/hepatitis ! G___P___A___
-Male & female- -Male & female- ! Preg complications