History Flashcards
1
Q
- Basic Information
A
Age, gender, ethnicity
2
Q
- Chief complaint
A
-What brought the patient into the hospital/office?
3
Q
- History of Present Illness
A
duration and character of primary complaint, associated symptoms, and exacerbating/relieving factors
4
Q
- Past History
A
any illnesses (hypertension, diabetes), hospitalizations, emergency room visits, transfusions, or surgeries
5
Q
- Allergies
A
reactions to any medications including severity (differential between actual allergy or adverse effect)
6
Q
- Medications
A
current or previous medications, including prescription or over-the-counter
7
Q
- Family History
A
any family medical history that can predispose a patient (cancers, cardiovascular disease)
8
Q
- Social History
A
patient’s functional status at home, social and economic circumstances, and goals and aspirations for future
9
Q
- Review of systems
A
questions about each major body system (to avoid anything that could be overlooked)
