History

Question 1

Order of history

Answer 1

CC
HPI
PMH
Fam Hx
Soc Hx
ROS

then PE

Question 2

CC

Answer 2

what brings you here TODAY?

Goals/Q’s for today?

Question 3

HPI

Answer 3

for each symptom:
SOCRATES (site, onset, char, rad, allev/assoc, timing, experienced b4?, severity)
associated sx
impact of sx
explanatory model

Question 4

PMH

Answer 4

1. Maj illness/hospitalizations (DM, MI, BP, chol, depression, asthma)
2. Surguries/Injuries
3. Meds
4. Allergies
5. Repro Hx (pregnancies, # children)
6. CAM
7. Prevention (vaccines, pap,mamm,colonscp,B/T self-exam)
8. Sexual Hx (active? w/?)
9. occ/enviorn
10. domestic violence

Question 5

Fam Hx

Answer 5

Age, health, cause of death, problems

Question 6

Social Hx

Answer 6

1. exercise
2. diet
3. tobacco
4. EtOH
5. rec. drugs/non-Rx
6. Financial
7. employment/military
8. living situation
9. relationships
10. support/religous

Question 7

ROS

Answer 7

1. gen/skin/sleep
2. HEENT
3. RESP
4. CV
5. MSK
6. Neuro
7. ENDO
8. GI
9. GU
10. Genital/sexual
11. GYN