ADULT MEDICAL HISTORY PRACTICE CHECKLIST The student: Presents him/herself correctly (name/ position Medical Student) Asks

s and/or uses correctly Patients name Asks for Chief Complaint using open ended questions Asks for Onset of Symptoms Asks for Description of Symptoms Asks for Frequency or Progression of symptoms over time [if applicable] Asks for Duration of symptoms Asks for Localization of symptoms (requests patient to point where) Asks for Irradiation of symptoms [if applicable] Asks patient to describe or compare the Quality / Characteristics Asks for the Intensity or Functional Impairment (1-10 or compare) [if applicable] Asks for improving AND worsening/provoking factors Asks for any medications AND remedies being used including dose, route, name and frequency of use Asks for pertinent positive and negative signs and symptoms associated with the chief complaint (pertinent ROS) Asks if someone has similar symptoms Inquires about Childhood illnesses: measles, rubella, mumps, whooping cough, chicken pox, rheumatic fever, scarlet fever and polio Inquire about Childhood chronic illnesses Asks about Adult Illnesses: - Medical- diabetes, hypertension, hepatitis, asthma, HIV disease, number and gender of sexual partners, at-risks sexual practices - Obstetric/gynecologic- obstetric hx. ,menstrual hx., birth control, sexual functions - Surgeries- dates, indications, and types of operation - Psychiatric- dates, diagnosis, hospitalizations, and treatments Inquires about Hospitalizations Inquires about Immunizations Inquires about Allergies Inquires about Accidents Inquires about Screening Tests (depending on age)- tuberculin tests, Pap smears, mammograms, stools for occult blood, and cholesterol tests, with the results and the dates they were last performed Inquires about Family History- outline the age and health or cause of death of each immediate relative, including parents, grandparents, siblings, children, and grandchildren. Asks specifically for: hypertension, coronary artery disease, elevated cholesterol levels, stroke, diabetes, thyroid or renal disease, cancer (specify type), arthritis, tuberculosis, asthma or lung disease, headache, seizure disorder, mental illness, suicide, alcohol or drug addiction, and allergies. Inquires about Marital Status and Household members Inquires about Occupation Inquires about Religious Beliefs Inquire about ADL if pertinent (in old patients) Inquires about Dietary and Exercise habits Inquires about Smoking / Tobacco products- ask how many, for how long Inquires about Alcohol use

YES NO

Inquires about Illicit Drug Use Reviews: General symptoms (Fever, Weight Changes OR fatigue) Reviews: Skin- Rashes, lumps, sores, color changes Reviews: Neurologic symptoms- Headache, head injury, dizziness, lightheadedness Reviews: Visual symptoms- vision, glasses or contact lenses, last examination, pain, redness, double vision, blurred vision, cataracts, glaucoma Reviews: ENT symptoms- Hearing, tinnitus, vertigo, earaches, infection, discharge, frequent colds, nasal stuffiness, itching, hay fever, nosebleeds, sinus trouble, condition of teeth, gums, bleeding gums, dentures, sore tongue, dry mouth frequent sore throats, hoarseness Reviews: Neck symptoms- lumps, swollen glands, goiter, pain or stiffness in the neck Reviews: Breasts- lumps, pain or discomfort, nipple discharge, self-examination practices Reviews: Respiratory symptoms- Cough, sputum (color, quantity), hemoptysis, dyspnea, wheezing, pleurisy, last chest x-ray, asthma, bronchitis, emphysema, pneumonia, and tuberculosis Reviews: Cardiovascular symptoms- heart trouble, high blood pressure, rheumatic fever, heart murmurs, chest pain or discomfort, palpitations, dyspnea, orthopnea, paroxysmal nocturnal dyspnea, edema Reviews: Abdominal / Gastrointestinal symptoms- heartburn, nausea, vomits, diarrhea, change in bowel habits, rectal bleeding or black/tarry stools, hemorrhoids, constipation, abdominal pain, food intolerance, excessive belching or passing of gas, jaundice, liver or gallbladder trouble, hepatitis Reviews: Renal / Urinary symptoms- polyuria, nocturia, urgency, burning or pain on urination, hematuria, urinary infections, kidney stones, incontinence. In males hesitancy, dribbling Reviews: Gynecologic (in females)- age at menarche, regularity, frequency, duration of periods, amount of bleeding, bleeding between periods after intercourse, last menstrual period, dysmenorrheal, premenstrual tension, age at menopause, menopausal symptoms, sexually transmitted diseased, vaginal discharge, itching, sores, lumps, STDs, number of pregnancies, number and type of deliveries, number of abortions ( spontaneous or induced) complications of pregnancy, birth control methods. Sexual preferences, interest, function, satisfaction, - Urologic (in males) symptoms- hernias, discharge from or sores on the penis, testicular pain or masses, history of STD and their treatments, sexual habits, interest, function, satisfaction, birth control methods, condom use and problems Reviews: Peripheral Vascular- intermittent claudication, leg cramps, varicose veins, past clots in the veins Reviews: Musculoskeletal symptoms- muscle or joint pains, stiffness, arthritis, gout, backache. (ask for swelling, erythema, pain, stiffness, weakness, or limitation of motion) Reviews Hematological symptoms: anemia, easy bruising or bleeding, past transfusions and/or transfusion reactions Reviews: Endocrine Symptoms- Thyroid trouble, heat or cold intolerance, excessive sweating, excessive thirst or hunger, polyuria Reviews: Emotional/Psychiatric symptoms- Nervousness, tension, mood, including depression, memory change, suicide attempts Closes interview in an appropriate manner

Developed by the Clinical Skills and Standardized Patient Program Office, University of Puerto Rico, School of Medicine, 2003
Copyright 2003- All rights reserved. No part may be reproduced or transmitted without written permission