Patient History Questions: Identifying Data: Age, Gender, Marital Status Chief Complaint: What brought you to the

hospital? HPI: When did it start? Where did it start (physically)? What does it feel like (characterize pain)? Can you rate pain on scale of ! "? #o$ often, #o$ long, #o$ %any? What setting did this occur (surrounding en&iron%ent'conte(t)? )oes anything %ake it $orse'better? )id you notice anything associated $ith pri%ary sy%pto%? MedicationsWhat %eds? What dose? What route? What fre*uency? Supple%ents? +irth Control? #erbals'+otanicals? AllergiesAre you allergic to any %edications'e&er had a reaction to any %edication? Any food'en&iron%ental Allergies? Tobacco/Alcohol/Drugs(Can be asked here or in personal'social h() )o you s%oke? #o$ long? #o$ %uch? #o$ often? Can you tell %e about your drinking habits? )o you use illicit drugs? Past History: Childhood)id you ha&e any %a,or childhood illnesses (%u%ps'%easles'chicken po()? Any chronic childhood illnesses? AdultMedical#a&e you been diagnosed $ith any illnesses as an adult (diabetes, hypertension, hepatitis etc.)? SurgicalCan you tell %e about any %a,or surgeries you/&e had? When? 0or $hat? What type of operation? 1b'GynAny pregnancies? Can you tell %e about your %enstruation history? 1nset, describe cycle? #o$/s your se(ual function? 2sychiatric- Any history of psychiatric illness? ()iagnosis, hospitalization, treat%ent) #a&e you gotten your i%%unizations (tetanus, polio etc)

3b, 2ap s%ear, %a%%ogra%, cholesterol? Family Hx: Can you tell a bit about your father/s health (age, or cause of death)? )iagnosed $ith anything? #o$ bout your %other? +rothers? Sisters? Grandparents? Grandchildren? Any history of hypertension, stroke, diabetes, thyroid'renal disease? Arthritis, 3+, 4ung disease, %ental illness (suicide), substance abuse? Personal/Social History: What do you do for a li&ing? #o$ far along in school did you get? What is it like at ho%e? Any significant others? #o$ is the relationship? Any significant sources of stress (i%%ediate' on!going)? 5eligious'spiritual beliefs? Acti&ities of )aily li&ing (especially elderly)? )o you e(ercise %uch? What is your usual daily food intake? Caffiene? Any alternati&e health care? Re ie! of Systems "#ons of $uestions% Start &road'()arro! it Do!n*: GeneralWhat is your usual $eight? #a&e you had significant loss'gain? Any recent $eakness, fatigue, fe&er? SkinHEENT#a&e you noticed any changes in your skin (rash, sores, lu%ps)? #ead- #o$/s the old noggin? Any headaches, dizziness, light! headedness? 6yes- #o$ is your &ision? Any changes? Any pain, redness, double'blurred &ision? What about glauco%a7 any cataracts? 6ars- #o$ is your hearing? Any changes? Any ringing, earaches, infection? )o you use hearing aids? 8ose- )o you ha&e any nasal'sinus trouble? 0re*uent colds, stuffiness, nosebleeds, hayfe&er? 3hroat-#o$ is your teeth and gu%s? When $as the last ti%e you $ent to see the dentist? Any soreness' sores? Sore!throats?

NeckBreasts-

#o$ is your neck, any recent pain or stiffness? #a&e you noticed any recent abnor%al changes in your breasts? 2ain, lu%ps, discharge? Respirator - #o$ is your breathing'lungs? #a&e you had any recent trouble? Any

cough, sputu% (color, *uantity), shortness of breath, $heezing? Any asth%a, pneu%onia, e%physe%a, 3+? C!"!G!#!#o$/s your ticker? Any heart trouble? #igh blood pressure? Any recent chest pain, palpitations? #a&e you had a recent 69G or other heart test? 4et/s talk about you sto%ach and bo$els. Any recent trouble $ith your sto%ach? Chronic heartburn? Any changes in appetite? 8ausea7 trouble s$allo$ing? #o$ are your bo$el %o&e%ents? Are they regular? Any changes in fre*uency? )iarrhea or constipation? Gas? Any blood in stool? 3rouble $ith he%orrhoids? )o you ha&e any abdo%inal pain? 8oticed any food intolerance? Any li&er'gallbladder trouble (,aundice'gall stones'hepatitis)? #o$ is your bladder? Any recent changes, recent proble%s? )o you ha&e any proble%s holding it? )o you go fre*uently (characterize)? Any pain'burning $ith urination? Any recent infection? #a&e you noticed any blood? 5educed force of strea%? Any hesitancy, dribbling? M1hh the things $e get to ask as physicians. #o$ is your bait and tackle' nuts and bolts? (Seriously) #a&e you had any changes or proble%s recently $ith your penis or testes? Any sores or recent discharge? #ernias? Any history of Se(ually 3rans%itted :nfections? Condo% use? Se(ual habits? Any functional proble%s? Any recent changes $ith your testes (s$elling, tenderness)? #a&e you had any recent proble%s in your &agina'uterus? Any recent proble%s'concerns $ith your periods? Age of first %enarche? Can you describe your %enstrual cycle (fre*uency, duration, a%ount)? Any changes? Any bleeding bet$een periods or after intercourse? :f appropriate- $hen did you begin %enopause? Any %enopausal sy%pto%s (hot flashes etc). #a&e you noticed any &aginal discharge or abnor%alities of your &agina (sores, itching, S3:/s)? Any pregnancies (;, and type of deli&ery). )id you ha&e co%plications? +irth control? Any abortions (spontaneous'induced)? What is your se(ual preference? :nterest'function?

$rinar -

Genitals-

0-

Peripheral +ascular: #o$ is your circulation? Any proble%s $ith your &eins (&aricose'clots)? ,uscolos-eletal:

#o$ are you %uscle',oints feeling? Any pain or stiffness? Any back pain? Any s$elling, redness, tenderness, loss of %otion? Can you elaborate? Any trau%a? )eurologic: #a&e you had any recent fainting spells or seizures? Any paralysis or loss of sensation or tingling? Hematologic: Any recent changes in ter%s of bruising or bleeding? Any history of ane%ia? Any past transfusion? .ndocrine: #a&e you had any thyroid trouble? Any changes in te%perature intolerance? 5ecent e(cessi&e s$eating or thirst? Pyschiatric: May ha&e already discussed #o$ is your %ood? #o$ $ould you describe yourself (ho$ $ould people close to you describe you)? Any increase in an(iety? Suicide atte%pts?