Intro and patient’s comfort:

1. Hello, I am going to quickly sanitize my hands to prevent the spread of infection.

a. Shakes Hands
2. My name is (YOUR NAME) and I am a first year medical student with American university of
ANTigua . My attending has asked me to obtain a comprehensive medical history so that we
can provide the best treatment possible for you. Is that okay with you?
3. Can you confirm your name and date of birth please? Lynzey Charles jan 26 1980
a. Repeat name/
b. Is it okay if I call you Ms./Mr...?
4. Now, what ethnicity do you identify with? Afro-caribean
a. Thank you.
5. I want to let you know that everything said here will remain confidential between you, me,
and my attending physician. So please feel free to speak freely.
6. Are you comfortable?
a. Is there anything I can get you before we begin?
7. Okay, what brings you in today?

History of Present Illness (HPI):

Chief Complaint:
8. Symptoms:

9. Onset
a. When did this first start?
10. Characteristics
a. How would you describe the pain?
i. Does it come and go?
b. Could you point to the location?
11. Radiation
a. Does the pain move to other places?
12. Associated symptoms
a. Have you noticed any other symptoms? (nausea, vomiting, fever)
b. How long does the pain last?
c. How often?
13. Exacerbating symptoms
a. Does anything make it better
i. ice, laying down etc.
b. Does anything make it worse?
14. Scale
a. On a scale from 1-10, ten being the worst pain in your life, could you please rate
your pain for me?
15. Review Chief Complaint/Summary
 Ok so I just want to quickly review what I have written down so far with you
16. Do you have anything else you would like to add?

Past medical History:

Okay, thank you, now I will ask you some questions about your past medical history.
1. Do you currently have any ongoing chronic illnesses?
a. Diabetes, high/low blood pressure, cancer high cholesterol.
2. Did you have any significant childhood illnesses?
a. Chicken pox, measles, rubella, mumps, whooping cough, rheumatic fever, scarlet
fever, or polio?
3. Have you ever been diagnosed with any mental health illnesses?
a. Anxiety, Depression, etc.
i. (If yes), have you been treated for it?/ Would you like to talk about it?
ii. Offer counseling We have more information regarding x I will make sure you
get this prior to leaving so you can better deal with x
4. Have you experienced any traumatic events?
a. War, death in the family
5. When was the last time you visited a doctor?
a. What was that visit for?
b. How did that visit go?
6. Are your immunizations up to date as far as you know?
a. Covid vaccine ? company and dose?
b. Have you had any blood work done in the past or recently, which showed anything
significant?
7. Do you have any allergies?
a. Food?
b. Environmental?
c. Medication?
d. Any other allergies?
WHAT ARE YOU SYMPTOMS WITH YOU ALLERGIES?
8. Do you take any prescription medicine?
a. Name:
b. Dosage:
c. How often?
d. How ingested?
e. How long?
i. Months/Years?? 1 year
9. Do you take any over the counter medicine? Why?
a. Name:
b. Dosage:
c. How often?
d. How ingested?
e. How long?
 i. Months/Years??
10. Any herbal products or supplements? (Any vitamins?)
a. Name:
b. Dosage:
c. How often?
d. How ingested?
e. How long?
i. Months/Years??
11. Have you had any surgeries or operations?
a. Shoulder surgery, abdominal surgery, exploratory surgery
12. Have you ever been hospitalized?
a. (If yes) I'm so sorry to hear that, what happened?
b. Have you ever had any blood transfusions?

13. (If woman) When was your last menstrual cycle?

a. Would you say that your menstrual cycles are relatively normal?
i. (If older woman) When did you go through menopause?
1. How long have you been in menopause?
b. About how long do they last?
c. When was the last time you received a Pap smear?
i. Was everything okay?
ii. Do you regularly receive a pap smear?
IF OVER 40: Have you ever received a mammogram?
-How long ago was it?
-Was it normal?
14. Thank you so much.
a. Now I will ask some more personal questions regarding your current lifestyle. I just
want to reiterate that everything said here is confidential between my attending,
you, and I. I want to let you know that I ask all my patients these questions, but
please let me know if you feel uncomfortable at any time.

Social History:
1. What is your marital status?
a. Do you have any kids?
i. (If yes) How many?
ii.
b. (If woman) Were there any complications with the delivery(s)?
c. Were the birth(s) full-term vaginal birth(s)?
d. (C-section or pre-term?)
2. Are you currently sexually active? Have you been in the past?
a. With multiple people or one person?
b. Do/Did you practice safe sex?
c. Do/Did you use contraceptive?
i. We have some pamphlets on different options if you are interested?
 d. Have you ever had any Sexually transmitted diseases?
i. syphilis, HIV/AIDS, chlamydia
3. How is life at home?
4. Who do you live with?
5. Where do you work? (Do you still work?)
a. How is it?
b. What does your daily routine look like?
6. Do you exercise?
a. What kind of exercise do you do?
7. How is your diet?
a. What does your diet usually consist of?
i. Describe the types of food you eat
8. Do you use tobacco/vaping/nicotine chewing gums?
a. Do you smoke it or chew it?
b. How long?
c. How many a day?
If yes: I just want to let you know that with smoking you increase your risk of
developing lung cancer.
And for how long have you been smoking?
d. How do you feel about your tobacco use?
i. Would you be interested in quitting?

9. Do you drink alcohol?

a. How long?
b. How much/how many per day?
c. (If excessive use of alcohol, offer counseling)
How do you feel about drinking alcohol?

10. Do you use any recreational drugs or pills?

a. Marijuana
11. Do you use any other drugs?
a. opioids
13. Thank you so much. Now I would like to ask you a few questions about your family history,
if that's alright?

Family History:
1. Are your mother and father still with us?
2. If ALIVE
a. How old are they?
b. Are they healthy?
3. If DECEASED
a. I'm so sorry to hear about that. Are you doing okay?
b. How long ago did they pass?
 c. How old were they?
d. Do you know how they passed?
i. If you feel that you may need to talk to someone we do have some
counseling services available, I can share that information with you later if
you would like.
4. Are there any chronic illnesses that run in the family that you know of?

a. Diabetes, high/low blood pressure, cancer, alcoholism, stroke, heart attack?

5. Do you have any other family members with significant medical issues?

Review of Systems (R.O.S.):

1. Thank you so much for your patience, we are almost finished. Now, I would like to review
your overall health...(point on your body each topic to help guide the patient)
2. Head:
a. Any issues moving your head?
b. Any headaches?
i. Headache, dizziness, lightheadedness?
3. Eyes
a. Do you wear glasses? Do you wear contacts?
b. Last eye exam? How did it go?
c. Any problems seeing?
i. pain, vision loss, blind spots etc.
4. Ears
a. Any problems hearing?
i. Ringing, vertigo, ear aches, sinus trouble
5. Nose:
a. Any problem smelling?
i. Nasal discharge, irritation, nose bleeds, sinus trouble?
6. Mouth:
a. Any problems eating/chewing, tasting, speaking or moving the tongue?
i. Sore tongue, dry mouth
7. Throat:
a. Any problems swallowing?
b. Any changes in your voice?
c. Any pain in that area?

8. Neck:
a. Any problems moving your neck?
i. Any pain, swollen glands
9. Respiratory:
a. Are you able to breath okay
b. Any coughing, discharge (quality/color), shortness of breath, pain with deep breath.
i. Asthma? Bronchitis, pneumonia, TB?
10. Cardio:
 a. Any chest pain or discomfort?
b. Irregular heart beat?
11. Gastrointestinal:
a. Any changes in appetite? Yes
i. Any heartburn?
b. Normal bowel/ urine movement?
i. any blood?
ii. Any burning?
c. Any abdominal pain? yes
12. MSK:
a. Any muscle or join pain?
i. Stiffness?
ii. Swelling?
b. Able to walk and perform daily tasks normally?
13. Skin:
a. Any changes in skin color?
b. Changes in color of moles?
c. Have you noticed any rashes, sores, or dryness?
d. Any itching?
e. Do you bruise easily?
14. Neurology:
a. Are you able to sense the difference in pressure, temperature, and sense vibrations?
b. Have you ever had any loss of consciousness?
15. Hair and Nails:
a. Any changes with your hair or nails?
16. Endocrine:
a. Have you noticed any increase in weakness or fatigue?
b. Have you noticed any temperature intolerance?
i. Too hot or too cold?
17. Alright, I have sufficient information right now, will conduct a physical examination and run
a few tests; then..
18. I am going to go speak with my attending. Hopefully we can figure out what is going on and
help you feel better today.
19. Do you have any questions for me?
(If she asks what we can do about her symptoms? I was able to gather a lot of info from our
interaction at this point however I need to still run some more tests and talk to my
attending physician and we will provide you with the most accurate info we can find once
we gather it. Does that sound ok?
20. Is there anything I can get you while you wait?
21. Okay, Thank you so much, it was very nice to meet you (shake hands). I will be back shortly.