Medical History Interview Notes

Name: M F Age: Date:

Chief complaint
(What brings you here today? Major concerns? Key questions/agenda/goals for appt?)

HPI
Symptoms
! Onset
! Palliation/Provocation
! Quality
! Radiation/location
! Severity
! Timeline (change)
! Experienced before

Associated Symptoms

Impact of symptoms
Acute? Chronic adaptation?
Functional impact

Explanatory model
What causing? What worried
about? Expectations of care?

PMH
! Major illnesses
! Hospitalizations
! Surgeries
! Serious Injuries
! Psych
(DM, MI, BP, !chol,
depression, HIV, hernia,
hysterectomy, chole)

Meds Allergies Repro Hx Prevention

! Pregnancies: ! Vaccines Y N
! # children: ! Seat belt Y N
! Helmet Y N
! Physical Y N
CAM ! Tests (circle):
o Pap/PSA
o Mammogram
o Colonoscopy
o B/T self-exam
Sexual History Active? Y N With? M W B Occ/Environ (exposures, Domestic violence
functional limitation, stress) (hurt/threatened at home, safe at home,
describe fights?)
 Family History Social History
Age, health, cause of death, problems
(Cancer, BP, heart, DM, EtOH, depression)
Father Exercise Diet Tobacco

Mother
EtOH (CAGE) Drugs Financial

Siblings
Employment ! Living sit.
! Relationships
Children ! Support
! Religious

Review of Systems
General/skin/sleep Respiratory Musculoskeletal Endocrine
! " weight ! Cough Blood? ! Joint pain/back ache ! Heat/cold intolerance
! Fatigue ! Dyspnea Sputum? ! Swelling ! Polydypsia
! Weakness ! Wheezing - Color? ! AM stiffness ! Polyphagia
! Fevers ! Asthma - Quantity? ! Arthritis ! Diaphoresis
! Chills ! Bronchitis ! Gout ! Thyroid problems
! Rash/itching/dryness ! Emphysema ! Cramps ! Diabetes
! " hair ! Pneumonia ! Prox. weakness ! Skin color change
! " nails ! TB ! Functional limit ! Excess hair growth
HEENT Cardiovascular Neuro/psych
! Eyes: o Vision ! High/low BP ! Headache
o Pain ! Murmurs ! Fainting
o Redness ! Orthopnea ! Blackouts
o Tearing ! Nocturnal dyspnea ! Seizures
o Double vision ! Edema ! Paralysis
! Chestpain ! Numbness/tingling
! Ears: o Hearing ! Palpitations (rapid/skip) ! Vertigo/dizziness/difficulty walking
o Tinnitus
! Claudication ! Confusion
o Vertigo
! Varicoseveins ! Memory loss
o Earache
o Discharge ! Thrmbophlebitis ! Tremor/coordination
! Easy bruise/bleed ! Anxiety/tension/stress
o Colds ! Anemia ! Depression/tearfulness
! Nose:
o Stuffiness ! Transfusions ! Suicide attempts
o Hay fever GI GU Genital/sexual Gynecological
o Nosebleed ! " appetite ! Dysuria ! Discharge ! Menarche age _____
o Sinus ! Heartburn ! Nocturia ! Itching ! Irregular period
o Anosmia ! Nausea ! Polyuria ! Sores ! Period freq _______
! Vomiting ! Hematuria ! STD ! Period duration ____
! Mouth: o Teeth ! Abd. Pain ! Urgency ! Hernias ! Bleed between
o Bleeding gums ! Bloating ! Hesitancy ! Test/vag pain ! Last period _______
o Sore throat ! Lactose intol. ! Incontinence ! Testicular mass ! Menopauseage ____
o Horseness
! Diarrhea ! UTI ! Interest ! Symptoms
! Constipation ! Stones ! Function ! Post-men bleed
! Throat: o Dysphagia ! Gas ! " stream ! Satisfaction ! Breast lumps
o Lumps
o Goiter ! Hemmorrhoids/rectal bleed ! Problems ! Breast pain
o Pain ! Liver/gallbladder ! Breast discharge
o Stiffness ! Jaundice/hepatitis ! G___P___A___
-Male & female- -Male & female- ! Preg complications