History & Physical Templet

Question 1

CC (Chief Complaint/Concern):

Answer 1

Simple, short, the reason for the visit (use patient’s words )

Question 2

HPI (History of Present Illness/Issues):

Answer 2

• New problem or complaint: chronological description since onset, including symptom analysis (location, quality, severity, timing, setting, alleviating and aggravating factors, associated signs and symptoms). Include pertinent negatives.
• PMH or FH relevant to CC
• Follow up of chronic condition or recent problem visit: description of interim history since last encounter
• Well visit: description of health related to the type of visit

Question 3

PMH (Past Medical History):

Answer 3

may break into additional sub-categories such as “Reproductive Health” for women, or “Pregnancy/Birth Hx” for infants, or “Growth and Development Hx” for children
• Age, general health status
• Allergies (meds, food/environment)
• Current medications (including OTC, supplements and botanicals)
• Major childhood/adult illnesses, serious accidents or injuries, transfusions
• Surgeries, hospitalizations including year and complications
• Psych, emotional status, mood disorders
• Environmental hazards (home or workplace)
• Health Habits:
o Contact/use of with health care system, last annual exam, what do you do when ill
o Recommended periodic screening with recent results
o Immunizations:
o Nutrition: nutritional preferences, eating disorder/challenges (highest/lowest wt), self assessment on1-10 scale and 1 thing to improve, last meal
o Exercise
o Sleep
o Substance use/abuse: tobacco, ETOH, recreational drugs, prescription drugs
o Safety: Domestic violence, seatbelts, guns in house, sun screen, environmental exposures, bike helmets, fire exits
o Stress levels and coping

Question 4

• GU (genitourinary)

Answer 4

• Voiding, Sexual activity, Contraception, STI Hx/Sx/Risk

* Women: Pregnancies, Menstrual hx, LMP, Breast/gyn cancers, procedures or problems

Question 5

FH (Family History)

Answer 5

• Parents, siblings and children: age and health status or cause of death
• Occurrence of genetic, or familial illnesses
• Genetic history affecting newborns
• Health of unrelated people living with patient

Question 6

SH (Social/Personal History):

Answer 6

• Life events: marital status, level of education, major life events
• Describe a typical day
• Personal: cultural practices, religious preference relevant to health
• Home: housing, housemates
• Occupation: type and risks
• Resources: financial, insurance and government programs, personal support systems

Question 7

ROS (Review of Systems):

Answer 7

those not addressed in HPI or PMH
•	Constitutional: overall health, weight, well being
•	Head/Eyes, Ears/Nose/Mouth/Throat, 
•	Cardiovascular/Peripheral Vascular
•	Respiratory, Breast
•	Gastrointestinal 
•	Genitourinary;
•	Musculoskeletal
•	Dermatologic/hair
•	Neurological, 
•	Psychiatric 
•	Endocrine 
•	Hematological/lymphatic 
•	Allergic

Question 8

Interviewer skills

Answer 8

• Develops rapport (introductions, eye contact, sensitivity, positive reinforcement)
• Uses variety of interviewing techniques (direct & indirect questions, reflection, summarizing, transitioning)
• Avoids medical jargon; uses clear questions dictated by client need
• Is patient focused: listens, and then responds.
• Is organized and knowledgeable with proper progression of questioning. Avoids duplication.