COLLECTING THE HISTORY Flashcards
Learn about what brought them in first.
What brings you in today?
When did that start? or That started…(clarification).
Characteristics of the problem.
Is it constant or does it come and go?
What makes it better?
What makes it worse?
What have you done to help treat it so far?
Is this the first time this has happened or has it happened before?
How would you rate it right at this moment?
What impact has this had on your daily activities?
Past medical history
Okay now that I know what brought you in today, why don’t we talk about your health history:
What allergies do you have?
What medications are you currently taking? Dose, frequency, route
Are you taking any supplements? Vitamins? Dose, frequency, route
What have you been hospitalized for in the past?
What surgical procedures have you had done?
History of blood transfusions? Reactions?
Last screening for mammogram, colonoscopy, etc. (if applicable).
Are you up to date on your vaccinations?
What illnesses/hospitalizations did you have as a child?
Family history
Are both of your parents still living?
Do you have a family history of heart disease? Stroke? Blood clots? Bleeding? Diabetes? Asthma? Cancer? Drug abuse/Alcoholism?
Social/behavioral history
How much alcohol do you drink on a daily basis?
Do you smoke? What and how much? What is your level of interest for quitting? If 0-no interest and 10-want to stop today.
Do you use any recreational drugs such as opiates, cocaine, amphetamines, marijuana?
Who currently resides with you in your home?
Do you feel safe at home?
How many hours of sleep do you get on average?
What do you do for physical activity?
How would you describe your diet? Standard/regular? Low sodium? Ketogenic? Vegetarian? Gluten free?
Have you fallen within the last year?
Are you having any depressive thoughts last longer than 3 weeks? Have you had any thoughts of self harm?
Review of Systems
General: Fever, aches, chills, pain, weight loss/gain
HEENT: Stuffy nose, sore throat, stiff neck, blurry vision, headaches, balance, difficulty hearing
Pulmonary: SOB, trouble breathing, hx asthma, COPD
Cardiovascular: chest pain, hx HTN, hyperlipidemia
GI/Abdominal: Diarrhea/constipation, frequency of bowel movements, any recent changes? History of GERD, Ulcers, appendicitis, surgeries, hernias
GU/GYN: burning/pain with urination, history of frequent UTIs, LMP, Gravid, Para, C-sections, Hx of kidney stones, renal failure, fibroids, hysterectomy, prostate problems
Mental: Difficulty concentrating, forgetfulness, depression, anxiety, stress
Neuro: History of falls, numbness and tingling, loss of sensation, problems walking
