Name:

D.O.B:
Patient Appearance :

Age:

M / F

Date:

CC:

HPI
Onset/Chronology Duration Timing Location Quantity (1-10) Quality Assoc. Symptoms Alleviators Aggravators Radiation Family w/ Similar Any trauma at onset? Patient Concerns?

What changed at time of onset?

PMH
Surgical Hx (Date, Complications) Hospitalizations Hx (Date,
Complications)

Medications
(Name, Dose, Frequency)
Vitamins Herbs

Allergies:
Meds Food Other

Social Hx
Occupation Education Food/Diet Partner Children Living Sit.

Immunizations:

Tobacco EtOH Drugs Exercise Safety Insurance Military background Legal hx Recent deaths/traumas/abuse

Alcoholism Cut Down Annoyed Guilty Eye-opener

Sexual Hx

Sexually Active? # of partners/ 6 months Orientation

Depression Sleep Changes Interest (loss) Guilt Energy Cog/Con Appetite Psychomotor Suicide

Frequency Concerns Satisfaction w/ Intercourse Age of 1st Intercourse # of Partners

Pregnancies Births Last Period

Family Hx
Father Mother Siblings

Tested for HIV, STD?

Children

Grandparents

CAD CHF HTN Lipids Stroke/TIA Cancer COPD Asthma GI Kidney Arthritis DM Thyroid CNS/PNS Psych

Y General Fatigue? Fever? Weakness? Weight ? Musculoskeletal Muscle/Joint Pain? Stiffness? Arthritis? Gout? Skin Hair ? Nail ? Lumps? Rashes? Hematological Bleed/Bruise Easy? Clotting trouble? Transfusions? Head Headaches? Trauma? Neuro Blackouts? Fainting? Numbness? Parastesia? (pins + needles) Tremors? Seizures? Speech Trouble? Weakness? Psychiatric Depression? Hallucinations? (Hear + See) Nervousness? Memory? Mood? Eyes Cataracts? Eye Exam? Glasses? Redness? Visual ? Ears Discharge Hearing ? Tinnitus (Ringing)? Vertigo (Spinning)? Nose/Sinus Stuffiness? Epistaxis (Nose Bleeds)? Rhinitis Sinusitis

N Mouth/Throat Teeth + Gums? Bleeding Gums? Hoarseness? Sore Throat? Last Dental Visit? Neck Lumps? Stiffness? Breasts Lumps? Pain? Nipple Discharge? Respiratory Cough? Dyspnea (Exertion Short Breath)? Painful Respiration? Wheezing? Sputum (color + quantity)? Asthma? Emphysema? Pneumonia? Tuberculosis (Chest X-Ray?) Hemoptysis (Coughing Blood)? Cardiac Chest Pain? Platypnea (Standing Short Breath)? Orthopnea (Laying Short Breath)? Paroxymal Noctnl Dyspnea (Wake)? Edema (Swelling)? Murmur? Rheumatic fever? Vascular Intermittent Claudication (Ms Pain)? Varicose Veins? Phlebitis (Blood Clots/Thrombosis)?

N GI Heartburn? Nausea? Vomiting? Indigestion? Irregular Bowel/Diarrhea? Swallowing Trbl/Dysphagia (Pain)? Hematemesis (Bloody Vomit)? Hematochezia (Black Tary Stole)? Ulcer? Hepatitis Jaundice (Yellow Eye Sclera)? Liver/Gallbladder Problems? Urinary Freq Urination ? Polyuria (Too Often)? Nocturia (At Night)? Dysuria (Painful)? Hematuria (Blood/Red)? Kidney Stones? Prostate Exam? Repro Vaginal/Penile Discharge? Erectile Dysfunction? Births? Dysmenorrhea (Pain Menses)? Amenorrhea (No Menses) Menarche (First Period)? Menopausal Symptoms ?

Vitamin D: Adapted from previous templates D.7