Name/ID: Age: DOB: / / Caffeine:__________________________________________________________________________________________

Sex: M /F Race: W B H A Admission date: / / Alcohol:__________________________________________________________________________________________

Chief Complaint: ___________________________________________________________________
___________________________________________________________________________________
History of Present Illness: 7 Dimensions of Pain
1 Chronology: How did it start? How long did it last? Was it constant or intermittent? Has this happened before?
2 Location: if abdominal, which quadrant? If thoracic, near what rib? R, L, bilateral. Radiation (through body or along
body surface like a belt – pancreatitis pain radiating through back, or laterally in both directions around to the back -
abdominal aneurysm pain straight through to back)?
3 Quality: Can you describe what the pain felt like? (lightheadedness – weakness, dizziness, presyncope)
Substance abuse:____________________________________________________________________________________
Education:_________________________________________________________________________________________
Occupation:________________________________________________________________________________________
Marital status: Single / Married / Divorced / Widow
Faith:_____________________________________________________________________________________________
Sexual History
Libido:_________________________________________Sex life:____________________________________________
STDs:__________________________________________Discharge:__________________________________________
Contraception:__________________________Last menstrual pd (duration, flow, regularity, req): __________________
Age at menarche:_______Age at menopause:________Pregs/births:_____/______Vaginal/C-
sections:______/_____Abortions:________

4 Quantity: On a pain scale of 1 to 10, where 0 is no pain and 10 is the worst imaginable or the worst you ever
experienced, how would you rate your pain? Does the pain change severity? How? If shortness of breath on exertion, #
of blocks, steps to cause difficult breathing? If orthopnea, how many pillows to sleep?

5 Setting: What were you doing when this started? Associated with eating? Lying down?

6 Aggravating and relieving factors: Does anything make it better or worse? After, how does the pain scale change?

7 Associated manifestations: Does anything else happen when you have the pain?

Notes______________________________________________________________________________
__________________________________________________________________________________

Past Medical History

Past Illnesses:_________________________________________________________________________
Childhood illnesses: ____________________________________________________________________
Hospitalizations: _______________________________________________________________________
Medical: ____________________________________________________________________________
Surgical: ____________________________________________________________________________
Medications/dosage:_____________________________________________________________________
_________________________________________________________________________________________________
Allergies: ___________________________________________________________________________
Immunizations:________________________________________________________________________
Cardiac risk factors: Dyslipidemia / HTN / DM /Central Obesity / Family Hx

Family History (ages, conditions, diseases- chronic, malignant, and hereditary, deaths)
Mother:________________________________________Father:_____________________________________________
Siblings:__________________________________________________________________________________________
Spouse/partner:_____________________________________________________________________________________
Children:__________________________________________________________________________________________
Relatives:_________________________________________________________________________________________

Social History
Tobacco (amount, duration):__________________________________________________________________________
Diet:_____________________________________________________________________________________________
Exercise:__________________________________________________________________________________________
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 Physical Exam Review of Systems
General appearance
Apparent state of health:______________________________Nutritional status: Slim / Cachectic / Obese / Nl General
Apparent age:________ Signs of acute/chronic disease:_____________________________________________________ Fever__________________________
Gait:_________________________________Dress:_____________________Hygiene:___________________________ Chills__________________________ Heart/Vascular
Cooperation:____________________________________Odor (alcohol, acetone, fecal, etc.):_______________________ Unusual sweats__________________ Chest pain or discomfort________________
Weight loss or gain_______________ Palpitation__________________________ Female genitalia
Vitals
Weakness or fatigue______________ Dyspnea with exertion__________________ Genital lesions_______________
BP:_____/_____RR:_____HR:___________Temp:_______Weight:________Height:________ Heat or cold intolerance___________ Orthopnea___________________________ Itching_____________________
Skin Paroxysmal nocturnal Discharge___________________
Color:_______________________Temp:______________Moisture:________________Edema:____________________ Skin dyspnea_____________________________ Dyspareunia_________________
Pigmentation:__________________________________Hair:______________________Nails:_____________________ Rashes_________________________ Syncope/near-syncope__________________ Age at menarche______________
Lesions/scars/textures:_______________________________________________________________________________ Pruritus________________________ Intermittent claudication________________ Frequency of periods__________
Tattoos/pierce:______________ Changes in skin color_____________ Lower extremity edema_________________ Duration of periods____________
Lymph Nodes: pain/tenderness: Changes in hair or nails____________ Amount of flow_______________
-Cervical- -submaxillary- -submental- -occipital- -preauricular- -post. auricular- -epitrochlear- -axillary- Piercings_______________________ Breasts Date of last period____________
Head (skull, scalp, face- shape, size, symmetry, swelling):__________________________________________________ Lumps or masses_________________ Lumps or masses______________________ Dysmenorrhea________________
Eyes (positions, lids, conjunctiva, sclera, corneas, irises):___________________________________________________ Bruising or bleeding______________ Discharge____________________________ Metrorrhagia_________________
EOMs:________________________________________Pupils: -equal- -round- -reactive- -accomodation- Pain________________________________ Number of pregnancies_________
HEENT Self-examination______________________ Abortions___________________
Acuity:____________________________________Visual fields:____________________________________________
Dizziness_______________________ Term deliveries_______________
Funduscopy (red reflex, optic disk, vessels): _____________________________________________________________ Headaches______________________ GI Age at menopause_____________
Ears: Inspection:________________________________Weber:________________________Rinne:________________ Eyeglasses/contacts_______________ Appetite_____________________________ Menopausal symptoms_________
Acuity:________________________________________Otoscopy:___________________________________________ Change in vision _________________ Anorexia____________________________ Postmenopausal bleeding_______
Nose (inspect, turbinates, sinuses, olfaction):_____________________________________________________________ Blurry vision____________________ Polydipsia___________________________
Mouth (jaw motion, lips, mucosa, tongue, teeth, palates, tonsils):______________________________________________________ Visual loss______________________ Dysphagia___________________________ Musculoskeletal
Neck (inspect, flexibility, trachea, thyroid):______________________________________________________________ Diplopia________________________ Odynophagia_________________________ Muscle weakness_____________
Chest/Lungs (shape, resp mvts, expand/retract): P:_____________________________ A:_________________________ Eye pain________________________ Heartburn____________________________ Stiffness____________________
Tactile fremitus: P:_____________________________A:_________________________ Excessive tearing or Nausea______________________________ Myalgias____________________
Percussion (dullness, resonance, dia. excursion): P:_____________________________ A:_________________________ discharge_______________________ Vomiting____________________________ Arthralgias__________________
Ausc (vesicular/symm or abn breath sounds): P:_____________________________ A:_________________________ Photophobia____________________ Diarrhea_____________________________ Joint swelling________________
CV: Neck: JV palp: Carotid pulse (palp, ausc):_____________________________________ Redness of eyes__________________ Constipation_________________________ Back pain___________________
Scotomata______________________ Melena______________________________
Heart (pulsation, PMI, percussion):__________________________________________________________________
Difficulty hearing________________ Hematochezia________________________ Neurologic
Sounds (rhythm, S1/S2, S3/S4 splitting):_____________________________________________________________ Tinnitus________________________ Change in bowel habits_________________ Focal weakness or
A,P,T,M (timing, shape, location, pitch, snap, rub, click):________________________________________________ Epistaxis_______________________ Abdominal pain_______________________ paralysis____________________
Abd: (skin, umbil., shape, size, symm, distention henias, scars):______________________________________________ Nasal congestion or rhinitis_________ Food intolerance______________________ Vertigo_____________________
Ausc (bowel sounds, bruits):__________________________________________________________________________ Bleeding gums___________________ Seizures_____________________
Perc (liver, spleen):__________________________________________________________________________________ Sore throat______________________ Urinary Loss of sensation______________
Palp (tenderness, rebound, masses, h/s megaly, pulses):_____________________________________________________ Hoarseness _____________________ Frequency___________________________ Paresthesias__________________
Periph Vasculature Change in voice__________________ Urgency_____________________________ Tremor_____________________
Skin color: ________________________________Edema:_____________________Varicose veins:________________ Dysuria_____________________________ Memory loss_________________
Pulses: Radial:_________Femoral:___________Popliteal:_____________Ptib:________________Dpedis:___________ Neck Nocturia_____________________________ Gait disturbance______________
MuscSkel (size, symm, swelling, impairments, deformities, skin, ROM, tender, consistency) Lumps or masses_________________ Incontinence_________________________ Loss of coordination___________
Muscles:__________________________________________________________________________________________ Stiff neck_______________________ Hematuria___________________________ Mood changes________________
Flank pain___________________________ Nervousness_________________
Joints:____________________________________________________________________________________________
Chest
Bones (+spinal curvature):____________________________________________________________________________ Cough_________________________ Male genitalia
DTRs: Bicepts:____________Tricepts:____________Brachiorad:_____________Patella:__________Achilles:________ Sputum________________________ Penile lesions_________________________
Bbinski:___________________ Hemoptysis_____________________ Discharge____________________________
Mental Status: Orientation (person, place, time):_________________________________________________________ Pleurisy________________________ Scrotal masses________________________
Mood:_________________________________________Attention:___________________________________________ Dyspnea________________________
Speech (clarity, rate, pitch, fluency, hoarse):__________________________Posture/expression:____________________ Wheezing______________________
Memory (short/long):_____________________________Thought/perception:___________________________________
Cranial Nerves: 1O 2O 3O 4T 5T 6A 7F 8AT 9G 10V 11A 12H
Motor: (tremors, tics, muscle tone, strength, finger-to-nose coord, pronator drift):_______________________________
Sensory: (touch, pain, temp, vibration, Romberg propriocepton, graph/stereo):__________________________________
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