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34 Cards in this Set

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RECORDING INFORMATION (6)
Date
Time
Place
Author
Refering Physician
Occasion
SOURCE AND RELIABILITY (2)
Interview Source
Reliability of History
PATIENT PROFILE (7)
Name
Age
Race
Sex
Marital Status
City of Residence
Occupation
CHIEF COMPLAINT (1)
Identify Patient Problem(s)
HISTORY OF PRESENT ILLNESS (8)
Body Location
Quality
Quantity
Chronology
Setting
Aggravating Factors
Alleviating Factors
Associated Manifestations
PAST MEDICAL HISTORY (11)
General Health
Childhood Health
Major illnesses
Surgeries
Accidents and injuries
Obstetrical History
Screening Tests
Immunizations
Medical allergies
Current Meds
Current Treatment Modalities
You
Medical
FAMILY HISTORY

Ages & Health of:
Ages & Health of
Father & Mother
Siblings
Spouse & Children
FAMILY HISTORY (18)

DISEASE SCREENING
Epilepsy
Glaucoma
Mental disease
Headaches
Stroke
Bleeding
Anemia - sickle cell
Hypertension
Heart problems
Respiration
TB
Intestinal problems
Kidney disease
Cancer
Diabetes
Arthritis
Gout
Symptomes like patient
Head
Heart/Blood
Breathing
Abdominal
Overall
PERSONAL-SOCIAL HISTORY (2)

HOME ENVIRONMENT
Past Residence(s)
Home Atmosphere
PERSONAL-SOCIAL HISTORY (6)

SOCIAL ACTIVITIES
Education History
Work History
Military History
Community Activities
Religious Activities
Friendships
PERSONAL-SOCIAL HISTORY (6)

MARITAL – SEXUAL
Marriages, duration
Marital Satisfaction
Sexual Adjustment
Sexual Orientation
Use of Contraceptives
AIDS Prevention
PERSONAL-SOCIAL HISTORY (8)

PERSONAL HABITS
Sleep
Relaxation
Exercise
Dietary intake
Caffeine
Alcohol use/abuse
Smoking-tobacco use
Drug use/abuse
REVIEW OF SYSTEMS
.
REVIEW OF SYSTEMS
General (6)
Fatigue
Weakness
Weight Change
Fever
Chills
Night Sweats
INTEGUMENT (12)
Color
Pigmentation
Scaling – Dryness
Rash
Hives – Pruritus
Lesions
Bleeding
Nail Growth
Nail Texture
Hair Growth
Hair Texture
Hair Distribution
Skin (7)
Nail (2)
Hair (3)
HEAD (5)
Headache
Dizziness
Syncope
Convulsion
History of Trauma
EYES (9)
Visual Acuity
Eye glasses or contacts
Blurring
Diplopia
Pain
Redness
Tearing
Glaucoma
Cataracts
EARS (5)
Hearing
Tinnitus
Vertigo
Earaches
Discharge
NOSE (6)
Frequent Colds
Sinus trouble
Hay Fever – Allergies
Discharge
Nosebleeds
Change in Smell
THROAT AND MOUTH (10)
Last Dental Exam
Toothache
Dentures
Bleeding Gums
Sores – Lesions
Taste
Breath
Recurrent Infections
Sore Throats
Hoarseness
NECK (4)
Swelling – Lumps
Goiter
Pain
Limitation of movement
BREASTS (6)
Pain
Masses
Nipple Discharge
Self Breast Exam
Last Breast (non-self)
Last Mammogram
RESPIRATORY (14)
Pleurisy – Chest Pain
SOB
DOE
Cough
Sputum Production
Hemoptysis
Asthma
Wheezing
Bronchitis
Emphysema
Pneumonia
Tuberculosis
Night Sweats
Last Chest X-Ray
CARDIOVASCULAR (14)
Increased cholesterol
Last EKG
Palpitations
Heart Murmurs
Hypertension
Chest Pain
Angina
Rheumatic Fever
Dyspnea
Dyspnea on Exertion (DOE)
Paroxysmal nocturnal dyspnea (PND)
Orthopnea
Diaphoresis
Edema
Tests (2)
Heart (6)
SOB (4)
Other (2)
PERIPHERAL VASCULAR (5)
Leg cramps
Intermittent claudication
Varicose veins
Thrombophlebitis
Raynaud’s phenomenon
GASTROINTESTINAL (20)
Abdominal Pain
Appetite – Food intolerance
Weight Change
Belching, Reflux
Nausea, Vomiting
Hematemesis
Eructation – Flatulence
Diarrhea, Constipation
Frequency of Bowel Movements
Change in Bowel Movements
Hx Laxative use
Melena, Hematochezia
Steatorrhea
Jaundice
Hepatitis
Cholecystitis
Diverticulitis
Polyps
Hemorrhoids
History Upper GI, Barium Enema, Colonoscopy
GENITOURINARY (11)
Frequency of urination
Polyuria
Nocturia
Dysuria
Hematuria
Urgency
Hesitancy
Force of Stream
Incontinence
History of Infections
History of Stones
MALE GENITAL TRACT (10)
Discharge
Lesions
History of STD and treatment
Hernia
Testicular Pain
Testicular Masses
History of Self – Testicular Exam
History of vasectomy
Sexual Libido – Intercourse
Erection - Ejaculation
FEMALE GENITAL TRACT (18)
Age of Menarche
LMP
Regularity
Duration/Amount of bleeding
Metrorrhagia
Dysmenorrhea
Discharge/Odor/Irritation
Lesions
History of STDs and treatment
Last Pap/results
PMS symptoms
Gravida/para/ab
Complications of Pregnancy
Contraception
Age at Menopause
Menopausal symptoms
Post Menopausal Bleeding
Dyspareunia/Libido/Satisfaction
MUSCULOSKELETAL (10)
Joint Pain
Stiffness
Weakness
Muscle Pain
Muscle Cramps
Limitations of movement
Arthritis
Gout
Back Pain
Disability
HEMATOPOIETIC (7)
Anemia
Fatigue
Epistaxis
Easy bruising - bleeding
Past Transfusions - Reactions
Lymphadenopathy
HIV Serology
ENDOCRINE - METABOLIC (12)
Growth and Development
Thyroid Trouble
Temperature intolerance
Diaphoresis
Hair Growth and Patterns
History of Diabetes
Polyuria
Polyphagia
Polydipsia
Galactorrhea
History of Gout
Increased Cholesterol
NERVOUS (11)
Syncope – Fainting
Seizures
Weakness
Paralysis
Numbness
Tingling
Tremors
Involuntary movements
Ataxia
Dysphonia
History of Stroke
PSYCHIATRIC (7)
Nervousness – Anxiety
Insomnia
Mood
Memory
Personality – Behavior Change
History of Depression and Suicide
History of Psych Evaluation