5

PATIENT HISTORY

Identifying Data: name, age, race, sex
Chief Complaint: patient problem
History of Present Illness:
onset, progression, character, location, radiation,
duration, frequency, severity, alleviating or
aggravating factors, effect on patients life,
associated symptoms, prior symptoms,
treatments/medications, exposures (OPQRST or
OLD CARTS)
Past Medical History:
Allergies/Sensitivities: meds and what
happened, other severe rxns e.g. bees,
nuts
Medications: name, strength,
frequency, route, OTCs, CAMs
Medical History: cardiac, hypertension,
vascular, CVA,
diabetes/endocrine/thyroid, renal,
seizures, anemia, asthma/COPD,
GI/GERD/PUD, liver, bowel, arthritis,
infections/TB/STD, allergies, skin,
tropical/parasitic
Surgical: diagnosis, date, outcome,
complications
Childhood Diseases: measles, Rubella,
mumps, chickenpox, pertussis,
diphtheria, rheumatic fever, polio
Immunizations: childhood, hepatitis B,
flu vac, pneumovac, tetanus
Injuries: type, treatment, disability
Transfusions: reactions, antibodies
Pregnancy: gravid (# of pregnancies),
parity (# of kids), abortions
(spontaneous/surgical), complications of
pregnancy
Family History: cardiac/MI, vascular,
hypertension, stroke, asthma/COPD, TB, cystic
fibrosis, diabetes, thyroid, renal, arthritis, gout,
cancer (type), allergies, seizures, migraine,
mental illness, dementia, blood disease/anemia/
sickle cell, visual/hearing, glaucoma, STD, other
Social History: occupation, hobbies, family,
exercise, habits (caffeine, alcohol, tobacco, illicit
drugs/IV drugs), education, diet, military,
religious, travel, stress, sexual, exposures, pets,
culture, legal




REVIEW OF SYSTEMS:

General: wt change, energy, fever/chills,
appetite, sleep, malaise, fatigability
Skin: rash, lumps, pigment, redness/red streaks,
sores, nails, hair, hyperhidrosis
Head: headaches, dizziness, syncope, loss of
consciousness, head injury
Eyes: vision change/diplopia, discharge, pain,
correction type, photophobia,
Ears: pain, discharge, hearing, tinnitus, vertigo
Nose: pain, obstruction, discharge, smell, sinus
pain, epistaxis
Throat/Mouth/Neck: teeth, taste,
gums/bleeding, swallowing, throat soreness,
ulceration, voice, tongue, lump
Pulmonary: cough, mucous, wheeze, DOE,
hemoptysis, pain with respiration, dyspnea
Cardiovascular: chest pain, SOB, palpitations,
murmur, edema, orthopnea, nocturia, PND,
claudication, varicosities, DVT, phlebitis,
ulcerations, HTN, exercise tolerance
Breast: pain, discharge, lump, color change,
nodes
Gastrointestinal: ABD pain, radiation, N&V,
diarrhea, constipation, bowel changes, melena,
hematochezia, hemorrhoids, hematemesis,
heartburn, appetite, dysphagia, food intolerance
Genitourinary: dysuria, urgency, frequency,
dribbling, hesitancy, incontinence, discharge,
hematuria, sexual function, dysparunia,
testicular pain/mass, genital lesions, LMP/cycle,
flank pain, puberty onset, libido, pregnancies
Musculoskeletal: pain, ROM, stiffness,
swelling, redness, warmth, atrophy, deformity,
neck/back pain & ROM, scoliosis, injury
Neuro: seizures, tremor, weakness, paralysis,
sensation, coordination, balance, syncope, vision
Psychiatric: depression, anxiety/tension,
agitation, mentation, hallucinations, paranoid,
memory, personality change, concentration,
suicidal thought, mood, compulsion,
disinhibition, thoughts, stress
Endocrine: temperature intolerance, hair, voice,
polydipsia, polyphagia, energy, skin
striae/pigment, change glove/hat size, sweating,
wt change
Hematologic: anemia, bruising, bleeding,
abnormal blood cells