Professional Documents
Culture Documents
Chief complaint(s)
Allergies
Medical/chronic illnesses/conditions
Accidents/Injuries
Surgical history
Obstetric/Gynelogic
Psychiatric illnesses
Health Maintenance Data Immunizations (Tdap, HepB, HPV, Flu, Pneumovax, MMR) Sreenings Dental
Eye Gyn/mamm Testicular / rectal Travel in last year/ Military service Substance use smoking drugs alcohols Nutrition, (daily intake, caffeine, height and weight, satisfaction with with weight) Sleep (aids, pattern, enough sleep?) Exercise (frequency and type, ADLS for elders) Safety (seat belts, helmets, sunblock, smoke detectors Family History (illnesses, death/cause of death, age) (HTN, high cholesterol, CAD, stroke, DM, thyroid or renal
disease, cancer, arthritis, TB, asthma, lung disease, seizure, h/a, mental illness/suicide, alcohol/drug addictions, allergies)
friends (satisfaction?, activities) finances (source of income, dependents, healthcare coverage) living/family situation (home situation/members, who makes decisions, pets,
weapons, smokers)
Ears (hearing, tinnitus, discharge, vertigo, pain) Nose/Sinuses (frequent colds, stuffiness, bleeding, itching, discharge)
Mouth/ Throat (teeth/gums, sore throat, voice changes, dental care) Neck (stiffness/pain, masses, tenderness) Breasts (changes, masses/swelling, pain/tenderness, discharge, self exam) Respiratory (cough, sputum, dyspnea, wheezing, xray?) CV (chest pain, EKG, palpitations, orthopnea) GI (appetite, food intolerances, dysphagia, heartburn, n/v, bowel movements/changes/bleeding, constipating/diarrhea, abd pain, belching) GU (frequency of urination, urgency, pain, hematuria, UTIs, stones, incontinence, burning on urination)
discharge,itching, pregnancies, birth control methods, sexual patterns, problems with libido, sexual abuse)
Peripheral vascular (cramps, varicose veins, thrombophlebitis, edema) Muskuloskeletal (muscle/joint pain/tenderness, swelling, stiffness, limitations, assistive
devices)
Neuro (fainting, seizures, weakness, memory loss) Hematologic (easy bruising/bleeding, anemia) Endocrine (heat/cold intolerance, excessive sweating, thirst or hunger) Psychosocial history Self concept (strengths/weaknesses, change, goals/values/future) Stress (sources, coping
PHYSICAL EXAM
VITALS
Head Hair Eyes Ears Nose Mouth Lymph Neck Chest/Lungs Cardiovascular Abdomen Muskuloskeletal Neuro