Name: M/F VITAL SIGNS: BP: _____/_____ HR: ______ Resp: ______

Age: ______ Allergies: Temp: _______ Ht: _______ Wt: _______

HISTORY OF PRESENTING ILLNESS:

1. Char. of Pain-Complaint
2. Occurrence-Onset
3. Location
4. Duration
5. Exacerbation
6. Relief
7. Radiation
8. Associated Symptoms

Pain Scale: 1 2 3 4 5 6 7 8 9 10

PAST MEDICAL HISTORY: Surgical History: HEALTH HABITS:

Childhood Illnesses: (Measles-Mumps-Pox) (injuries, date, complications, transfusions)  Exercise Routine:
_________________
 Diet
 Tobacco (# packs)
 Alcohol
 Illegal Drugs
 Caffeine
 Travel History:
Medical Problems: (Date onset-Current Mgmt) Current Medications: (OTC, Alt Tx, vitamins)

 Immunizations:

 Screening exams
(PSA, Brst, Colon, Chol.)

 Seat belt
 Smoke alarm
 Bike helmet

REPRODUCTIVE/SEXUAL HISTORY: Pregnancy

 Gender of partners: Gravida: ____ Para: ____ Spont. Abort::____ Full term: ____ Complications: (DM,HTN)
 Contraception
 Sexual Dysfunction Menstrual History:
 HIV Risk (IV drug, transfusion<1985,sex for drug/$) Menarche: _______ Menopause: ______ Menses: ________________________________

SOCIAL HISTORY:
 Family Tree
Health Status
Cause of Death
Medical Cond’s
Ages

1. Upbringing-Hometown
2. Ethnicity-Nationality
3. School-Military
4. Work-Finances
5. Living Situation
6. Family-Relationships
7. Leisure
8. Religion
9. Stress-Goals-Outlook
10. Medical Costs-Insured
REVIEW OF SYSTEMS: REVIEW OF SYSTEMS NOTES:
A. General
___fevers ___sweats ___weight change
___exercise tolerance ___energy level
B. Dermatology
___rashes ___pruritus ___ moles ___lumps
___lesions
C. HEENT
___Head (h/a, trauma)
___Eyes (vision, glasses, diplopia, pain)
___Ears (hearing, tinnitus,vertigo,pain)
___Nose (epistaxis, obstruction,sinusitis)
___Mouth (dental care, dentures, sores, sore throat)
D. Breast
___lumps ___discharge ___pain ___swelling
E. Respiratory
___dyspnea ___pleuritic pain ___cough ___sputum
___wheezing ___asthma ___hemoptysis
___cyanosis ___snoring ___apnea ___TB exposure
___PPD
F. Cardiovascular
___chest pain ___dyspnea on exertion
___orthopnea ___paroxysmal nocturnal dyspnea
___edema ___murmur ___palpitations
___claudication ___HTN ___leg cramps ___DVT
G. Gastrointestinal
___appetite ___odynophagia ___dysphagia
___heartburn ___nausea ___vomiting
___hematemesis ___jaundice ___abd pain
___melena ___hmeatochezia ___diarrhea
___constipation ___bowel habits/color
___hemorrhoids
H. Genitourinary
___dysuria ___nocturia ___hematuria ___frequency
___urgency ___hesitancy ___urinary incontinence
___vaginal/urethral discharge ___sores
___dyspareunia ___testicular pain ___swelling
I. Endocrine
___polyuria ___polydipsia ___heat/cold tolerance ADDITIONAL NOTES:
J. Hematologic
___known anemia ___easy bruising ___heavy bleed
K. Musculoskeletal
___joint pain ___back pain ___swelling ___stiffness
___deformity ___muscle aches ___locking joints
L. Neurological
___dizziness ___involuntary movements ___speech
___syncope ___coordination loss ___paralysis
___motor weakness ___memory changes
___seizures ___paresthesias
M. Psychiatric
___depression ___sadness ___sleep disturbance
___crying spells ___anorexia ___hyperphagia
___anhedonia ___suicidal/homicidal ___loss libido
___anxiety ___eating disorders ___hallucination
___delusions ___behavioral changes
N. Functional Status (Activities of Daily Living)
___bathing ___ambulating ___toileting ___transfer
___eating ___dressing ___shopping ___cooking
___transportation ___telephone use ___laundry
___housekeeping ___meds/financial responsibility