ROBERTO ELAS DAMACIO BRETN

ENGLISH III

TAKING A HISOTRY
PERSONAL DETAILS
NAME:
DATE BIRTH:
MARITAL STATUS:
TELEPHONE
NUMBER:
OCCUPATION:

PRESENTING COMPLAINT
ONSET (DATE/MODE):

NATURE AND COURSE OF THE SYMPTOMS:

PRECIPITATING EVENTS:

FREQUENCY AND SEVERITY:

CURRENT MANIFESTATIONS:

CHARACTER AND QUALITY:

PAST MEDICAL HISTORY

ILLNESSES (ADULT/CHILDHOOD):

HOSPITAL ADMISSIONS:

SURGERIES:

TRAUMA/INJURIES:

BLOOD TRANSFUSIONS:

AGE:
SEX:
ADDRESS:
RELIGION:

34

ROBERTO ELAS DAMACIO BRETN

ENGLISH III

34

IMMUNIZATION & VACCINATION HX:

PSYCHIATRIC HISTORY:

TRAVEL HX:

CARDIAC RISK FACTORS (Male > 45 years old, Smoking, Obesity, Positive Family History, Diabetes
mellitus, High Cholesterol, Hypertension):

ALLERGIES
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____________________________

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DRUG HISTORY AND MEDICATIONS

NAME
____________________________
____________________________
____________________________
____________________________
____________________________

DOSE
____________________________
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____________________________
____________________________
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FREQUENCY TAKEN
____________________________
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FAMILY HISTORY

o
o
o
o

Heart Disease
High Blood Pressure.
Thyroid Disease
Diabetes

o
o
o
o

Cancer
Depression/Mental
Illness
Stoke
Lung Problems

o
o
o
o

Seizures
Blood Clots
Kidney Disease
Bleeding Problems

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ENGLISH III

34

o SOCIAL AND PERSONAL HISTORY

EVER USE TOBACCO?

YES NO

DATE STOPPED IF NO LONGER USING?

CURRENTLY USING CHEWING TOBACCO, SNUFF, PIPE OR CIGARETTES?

YES NO

ALCOHOL USE:

MORE THAN ONE DRINK PER DAY LESS THAN ONE DRINK PER DAY NEVER

CAFFEINE USE:
NEVER

MORE THAN TWO DRINKS PER DAY

TWO DRINKS OR LESS PER DAY

RECREATIONAL DRUGS (MARIJUANA, COCAINE, ETC.)

SEXUAL PREFERENCE:

MEN WOMEN BOTH

LIVE BY MYSELF

LIVE WITH

DO YOU HAVE ANY SPECIAL REQUESTS DUE TO RELIGIOUS PRACTICES / CULTURE / VALUES?
EDUCATION
OCCUPATION

OBSTETRIC
MENSTRUAL PERIODS:
LAST MENSTRUAL PERIOD:
MENARCHE:
SEXUAL LIFE:
PREGNANCIES:
MACROSOMIA:
BREASTFEEDING:
CONTRACEPTION:
PAP SMEAR:
MENOPAUSE:

ROBERTO ELAS DAMACIO BRETN

ENGLISH III

34

REVIEW OF SYSTEMS
SKIN

o
o
o

o
RASH
SORES
MOLES TO CHECK

EYES

o
o
o

BLURRY VISION
DRAINAGE VISION
DOUBLE VISION

LEG PAIN WHEN

WALKING

o
o
o
o

PAIN IN JOINTS
STIFFNESS IN JOINTS
SWOLLEN JOINTS
BACK PROBLEMS

LOSS/ECREASE OH
HEARING

DRAINAGE FROM
EARS

o
o
o

RINGING

INDIGESTION/HEART
HBRUN

FOOD
INTOLERANCES

o
o
o
o

DIARRHEA

o
o

VOMITING

SINUS
PROBLEMS/HAY
FEVER

LUNG/BREATHING

o
o

COUGH

COUGHING UP
BLOOD

WHEEZING

DIFFICULTY
BREATHING

HEART/CIRCULATION

o
o
o

SWOLLEN ANKLES

CHANGE IN APPETITE

SEXUAL PROBLEM

NERVOUS SYSTEM

INCREASE IN
HEADACHES

LOSS OF
CONSCIOUSNESS OR
FATINESS

o
o

SLEEP DISTURBANCE

TROUBKE WITH
SPEECH, BALANCE,
COORDINATION OR
WEAKNESS

TINGLINGIN ARMS
OR LEGS

CHANGE IN WEIGHT
PROBLEMS WITH
SWALLOWING

CONSTIPATION
ABDOMINAL PAIN
BLOODY OR BACK
STOOL
NAUSEA

URINARY

DIFFICULTY
URINATING

DISCOMFORT WHILE
URINATING

INCONTINENCE/ACCI
DENTS

HEART MURMUR
CHEST PAIN

DIGESTIVE

SORES IN MOTUH

URINATING
FREQUENTLY OR
GETTING UP MORE
THAN ONE TIME AT
NIGHT

SKELETON

o
o
o

EARS

DEPRESSED MOOD
OR ANXIETY

WOMEN

HEAVY OR PAINFUL
PERIODS

BLEEDING BETWEEN
PERIODS

VAGINALDISCHARGE
MORE/LESS THAN
MONTHLY

o
o

HOT FLASHES
PAST MENOPAUSE