Medical History

Question 1

HPI

Answer 1

Onset: date/time/duration
Provocative
Palliative
Quality
Quantified
Regionality
Radiation
Symptoms (associated)

Question 2

PMH

Answer 2

General Health
Chronic Illness
Surgical Procedures
Hospitalizations
Injuries/major illnesses
Medications
Allergies & reaction
Immunizations

Question 3

FH

Answer 3

Cancer
Hypertension
Heart Disease
Diabetes
Stroke
Seizures
Bleeding Disorders
Age/Health (parents/grand)

Question 4

Social History

Answer 4

Occupation
Education
Living Situation
Safe at Home
Diet 
Physical activity
Caffeine/alcohol/tobacco use
Prescription/illicit drug use
Military History
Travel
Sexually active
Number of Partners

Question 5

ROS: General

Answer 5

Weight changes
Fatigue
Malaise
Weakness
Fever/Chills
Sweats/Night sweats

Question 6

ROS: Skin

Answer 6

Rashes./sores/lesions
Lumps/masses
Pruritus (itching)
Dryness/moistures
Hair/Nail changes

Question 7

ROS: Head

Answer 7

Headaches
Head trauma
Dizziness/vertigo
Syncope/LOC/Concussion

Question 8

ROS: Ears

Answer 8

General Hearing Status
Otalgia (earaches)
Past Infections
Drainage/Discharge
Tinnitis

Question 9

ROS: Eyes

Answer 9

General Vision Status
Glasses/Contacts
Last Eye Exam
Pain/Redness/Tearing
Diplopia/blurriness
H/O trauma/foreign body

Question 10

ROS: Nose/Sinuses

Answer 10

Sinus pain
Epistaxis
Nasal Congestion
Nasal Drainage
Frequent colds
Sneezing

Question 11

ROS: Mouth/Throat

Answer 11

Dental Hygeine
Last Dental Exam
Tootaches
Pain/Soreness
Hoarseness

Question 12

ROS: Neck/Lymph nodes

Answer 12

Pain
Stiffness/limited ROM
Masses/Swelling
Tenderness/enlargement (lymph nodes)

Question 13

ROS: Breasts

Answer 13

Pain
Lumps/masses
Nipple changes/discharge
Self-exams

Question 14

ROS: Respiratory

Answer 14

Pleuritic chest pain
Cough/Sputum
Hemoptysis
Wheezing or H/O Asthma
H/O Bronchitis
TB or past exposure
Last PPD or CSR

Question 15

ROS: Cardiovascular

Answer 15

Pain
Palpitations
Diaphoresis
SOB/dyspnea
Orthopnea/PND
Edema
H/O HTN, murmurs, heart problems
EKG/other dx testing

Question 16

ROS: Gastrointestinal

Answer 16

Appetite
Food intolerances
Dysphagia (Solid/liquid)
Dyspepsia (heartburn)
N/V
Change in bowel habits
Constipation/diarrhea
Rectal bleeding/melena
Hemorrhoids
H/O PUD, Jaundice, Appendix, GB disease

Question 17

ROS: Genitourinary

Answer 17

Change in frequency, force of stream, color
Hesitancy/difficulty initiating
Pain/dysuria
Dribbling/incontinence
H/O infections, hematuria
Penile/vaginal discharge
H/O STD's/Treatment
Libido
WOMEN- Dyspareunia
MEN- Scrotal pain/mass/edema
           Erectile problems
           Self-testicular exams

Question 18

ROS: OB/GYN

Answer 18

Menarche
Last menstrual period
Gravida (# pregnancies)
Para (# deliveries)
Delivery complications
Abortions/miscarriages
Last pap (Results)
Menopause (Symptoms)

Question 19

ROS: Musculoskeletal

Answer 19

Intermittent claudication
Varicosities
Decrease strength
Decreased ROM
Joint swelling, redness, stiffness, pain
H/O bone/joint infections, fractures/dislocations, back pain/disc disease, sciatica

Question 20

ROS: Neurologic

Answer 20

H/O convulsions/seizures, infections/meningitis
Memory loss
Trouble Concentrating
Tremors
Numbness/sensory loss
Paresthesia (pins/needles)

Question 21

ROS: Hematologic

Answer 21

Easy bruising
Bleeding (gums/skin)
H/O transfusions, anemia, blood diseases

Question 22

ROS: Endocrine

Answer 22

Intolerance to heat/cold
Nervousness
Sleeplessness
Polyphagia/-uria/-dipsia
Nocturia
Tested for diabetes
H/O thyroid disease

Question 23

ROS: Psychiatric

Answer 23

Depression, mood changes
Anxiety, agitation
Tension, irritability
Suicidal thoughts
Sleep disturbances
Difficulty getting up