History of present illness

Question 1

location/radiation

Answer 1

Where does it hurt does it hurt anywhere else?

Question 2

quality

Answer 2

Can you describe the pain? For example a bee bite tends to cause a stinging pain.

Question 3

severity

Answer 3

How much does it hurt on a scale from 1 to 10.

Pain of 1 indicates the pain is not really bothering you.

Pain of 5 indicates the pain is interfering with life.

Pain of 1 indicates the pain preventing you from doing anything.

Question 4

onset
duration
frequency

Answer 4

When did the pain occur?

How long has it been going on?

Does it ever get better or worse?

Question 5

Environmental factors

Answer 5

Do you think you were somewhere or did something to set it off?

Question 6

what makes it better/worse

Answer 6

What makes it better/worse?

Question 7

associated manifestations

Answer 7

Is there anything else bothering you that you think may be related to your chief complaint?

Question 8

Have you ever had this before?

Answer 8

a. Prior Treatment? Response? Data from past charts?

b. What has patient done about the symptom

Question 9

6. Patient’s Perspective of the Illness

Answer 9

a. Patient’s understanding of the disease? Especially
causes/implications/fears
b. Impact of the disease and/or its treatment on the patient’s life, work,
relationships
c. Patient expectations
d. Patient’s reason for visit