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21 Cards in this Set
- Front
- Back
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General
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Usual state of health
Fever Chills Night sweats Weight changes Fatigue |
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Skin
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Rashes
Itching Hives Changes in moles Lumps or bumps Changes in hair texture Changes in nail appearance |
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Head
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Dizziness
Headache Fainting History of head injury |
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Eyes
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Blurry vision
Recent changes in vision Double vision Eye pain Redness Discharge Excessive tearing or dryness EyE injuries(if yes put in PMH) Spots before the eyes Night vision problems |
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Ears
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Difficulty hearing
Discharge Ear pain Ringing in the ears |
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Nose
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Nosebleeds (epistaxis)
Pain Discharge Frequent colds Sinus pain Hay fever (if yes goes in PMH) |
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Mouth/Throat
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Problems w teeth or pain
Most recent dental visit Problems with gums Chronic bad breath(halitosis) Hoarseness or voice changes Frequent sore throats Post nasal drip Lumps in the mouth or tongue Difficulty swallowing |
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Neck
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Lumps
Pain Stiffness Thyoid problems (if yes, put in PMH) Swollen glands |
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Chest (Lungs)
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Cough-productively nonproductive
Coughing up blood Discomfort (pain) Shortness of breath *advise smoking cessation |
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Heart / Cardiovascular
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Chest discomfort/pain (angina)
SOB: exertional When lying flat (orthopnea) Palpitations History of heart murmur Ankle swelling Last EKG? |
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Women
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Perform self breast exam
Lumps Pain Discharge Tenderness |
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Gastrointestinal
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Appetite changes (loss-anorexia, excessive-polyphagia)
Nausea/vomiting Constipation/diarrhea Heartburn Pain Vomiting blood (hematemesis) Blood in stools (hematochezia) Excessive belching or gas (flatus) Hemorrhoids Jaundice History of hepatitis (if yes put in PMH) History of liver or gallbladder disease (if yes put in PMH) Rectal pain Changes in bowl habits |
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GU (male/female)
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painful or burning urination
frequent urination (polyuria) urgency urinary incontinence Blood in urine (hematuria) Bedwetting (nocturnal enuresis) Urinary retention (can't pee) Foul urine or abnormal color |
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GU (Male only)
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frequent nocturnal urination (nocturia)
difficulty starting or stopping the stream dribbling urgency penile lesions erectile dysfunction scrotal masses testicular pain or masses able to enjoy sexual intercourse/loss of libido Hx of STDs-if yes put in PMH Fertility problems |
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GU (Female only)
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Lesionso f external genitalia
Vaginal itching Vaginal discharge Most recent pap smear Painful intercourse (dyspareunia) Able to enjoy sexual intercourse/loss of libido Fertility problems Hx of STDS Menstrual pain PRN-post menopausal bleeding |
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Peripheral vascular
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Pain in claves when walking
Varicose veins History of thrombophlebitis (blood clots-if yes put in PMH) Swelling Coolness of leg or foot Discoloration of extremity Loss of hair on legs Leg or foot ulcers |
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Musculoskeletal (MSK)
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Muscle or joint pain/stiffness
Joint swelling or redness Weakness in a limb Hx of gout (if yes, put in PMH) Back pain Deformities/Fractures (Fx or Fx's) Serious MSK injuries (if yes put in PMH) |
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Hematologic
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Hx of anemia (if yes put in PMH)
Easy bruising Abnormal blood clotting Use of warfarin (Coumadin) or Aspirin-if so put in PMH Hx of transfusion or transfusion reactions |
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Endocrine
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Heat or cold intolerance
changes in hair texture frequent hunger frequent thirst change in hat, glove, or shoe size |
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Neurologic
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Headaches
Fainting Dizziness Weakness in a limb Numbness/tingling Burning pain Tremors Monocular visual loss (amaurosis fugax) Memory loss Speech difficulties Unsteady gait Behavioral changes Loss of consciousness Disorientation Difficulty concentrating Involuntary movements Noises or whoosing in head |
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Psychiatric
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Mood changes or mood swings
Excessive nervousness or anxiety Hallucinations Paranoia Delusions Depression Thoughts of suicide (suicidal ideation) Thoughts of homicide (homicidal ideation) |
