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Presenting Complaint
Concise description of symptoms the patient feels - (e.g. Im short of breath)

History of Presenting Complaint

Onset - When did it all start? Acute or gradual Did it come on suddenly? Duration? Intermittent or continuous? Has it gotten worse? Pain SOCRATES Associated symptoms Dyspnoea, chest pain, orthopnea, palpitations, syncope, sweating, nausea

Ideas, Concerns & Expectations

Past Medical History

Any hospital admissions? when, where & why? Any operations? Dental work - if suspicious of infective endocarditis Any illnesses or conditions rheumatic fever, atrial fibrillation, thyrotoxicosis, cardiomyopathy? DEATH- diabetes, epilepsy, asthma, thyroid, hypertension?

Drug History
Do you take any regular medication? tablets, injections OTC drugs? Herbal remedies? Contraceptive pill? Oxygen? ALLERGIES?

Family History
Are there any illnesses that seem to run in your family? Are your parents still in good health? if deceased determine age and cause of death Any unexplained deaths in young relatives? Has anyone ever had any problems similar to what you are experiencing?

Social History

Smoking - How many smoked and for how long? Alcohol -How much each week (convert to units) Drug use - Recreational drug use can be a useful way to phrase it Diet - Fatty foods? Balanced? Exercise Living Situation House or bungalow? Who lives with you? Is there support if needed Activities of Daily Living - Has the illness impacted what you would normally do each day e.g. hoovering, digging, stairs Occupation? Hobbies?

Systemic Enquiry
Cardiovascular Chest pain, PND, Orthopnoea, SOB, Cough, Ankle swelling, Palpitations, Cyanosis Respiratory Cough, Sputum, Haemoptysis, Chest Pain, SOB, Tachypnoea, Hoarseness, Wheezing GI - Appetite, Diet, Nausea, Indigestion, Dysphagia, Pain, Bowel habit, Haematemesis, Jaundice Urinary - Frequency, Dysuria, Polyurea, Urgency, Hesitancy, Nocturia, Back pain, Incontinence Nervous System Visual/other senses, Headache, Fits/Faints, LOC, Weakness, Numbness Musculoskeletal Pain in muscles, bones & joints, swelling, gait Dermatology Skin changes, dryness, ulcers, rashes