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Medical History Checklist > Medical History Checklist > Flashcards

Medical History Checklist Flashcards

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1
Q

CC

A

Chief Complaint

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2
Q

HPI

A 
History of Present Illness
Onset: date/time/duration
Provocation
Palliative
Quality
Quantified
Regionality
Radiation
Symptoms: (Associated)
Timing: occurence, onset
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3
Q

PMH

A 
Past Medical History
General Health
Hospitalizations
Surgical Procedures
Illnesses
Injuries
Medications 
Allergies
Immunizations
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4
Q

FH

A 
Family History
Cancer
Hypertension
Heart Disease
Diabetes
Respiratory Problems
Seizures
Bleeding Disorders
Age/health (grandparents)
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5
Q

SH

A 
Social History
Occupation
Education
Socioeconomic Status
Living Situation
Sexual History
Physical Activity
Diet
Sleep
Caffeine Use
Alcohol Use
Tobacco Use
 Illicit Drug Use
Military History
Safe At Home
Prescription Drug Use
Out of Country Recently
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6
Q

ROS

A 
General
Skin
Head
Ears
Eyes
Nose/Sinuses
Mouth/Throat
Neck
Lymph Nodes
Breasts
Respiratory
Cardiovascular
Gastrointestinal
Genitourinary
Obstetrics/Gynecology
Extremities/Musculoskeletal
Neurologic
Hematologic
Endocrine
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7
Q

General

A 
Weight Changes
Fatigue
Malaise
Fever/chills
Sweats/nights Sweats
Weakness
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8
Q

Skin

A 
Rashes/sores/lesions
Lumps/masses
Pruritus (Itching)
Dryness/moisture
Hair/nail changes
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9
Q

Head

A

Headaches
Head Trauma
Dizziness/Vertigo
Syncope/LOC

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10
Q

Ears

A 
General Hearing Status
Otalgia (earaches)
Past Infections
Drainage/discharge
Tinnitus (ringing in the ears)
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11
Q

Eyes

A 
General Vision status
Glasses/contacts
Last eye exam
Pain/redness/tearing
Diplopia/blurriness
H/O trauma/foreign bodies
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12
Q

Nose/Sinuses

A 
Sinus Pain
Epistaxis (nose bleed)
Nasal congestion
Nasal drainage
Frequent colds
Sneezing
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13
Q

Mouth/ Throat

A 
Dental Hygiene
Toothaches
Last dental Exam
Pain/Soreness
Hoarseness
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14
Q

Nech

A

PAin

Stiffness/ Limited ROM (range of motion)

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15
Q

Lymph Nodes

A

Tenderness/enlargements

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16
Q

Breasts

A

Pain
Lumps/masses
Nipple Change/Discharge
Self Exams

17
Q

Respiratory

A 
Pleuritic Chest Pain
Cough/Sputum
Hemoptysis (blood in sputum)
Wheezing or H/O asthma
H/O bronchitis
TB or past exposure
Last PPD or CXR
18
Q

Cardiovascular

A 
Pain
Palpitations
Diaphoresis
SOB/Dyspnea
Orthopenea (SOB laying flat)/ PND (waking and gasping for air)
Edema
H/O Hypertension
H/O Hearth murmurs
H/O heart Problems
EKG/ other dx testing
19
Q

Gastrointestinal

A 
Appetite
Food intolerance
Dysphagia (solid/liquid)
Heartburn
Nausea/vomiting
Change in bowel habits
Diarrhea/constipation
Rectal Bleeding/ Melena (tarry stool)
Hemorrhoids
H/O PUD (peptic ulcer disease)
H/O Jaundice
H/O Appendix/ Gall Bladder Disease
20
Q

Genitourinary

A 
Change of Frequency
Change of Force of Stream
Normal Color or Change in Color
Hesitancy/difficulty to initiate
Pain/Dysuria
Dribbling/Incontinence
H/O infections
H/O hematuria
Penile/Vaginal discharge
H/O STI's/ Treatment
Libido
WOMEN ONLY: dyspareunia (painful intercourse)
MEN ONLY: Scrotal pain/mass/edema
 Erectile problems, Self Testicular Exam
21
Q

OB/GYN

A 
Menarche
Last Menstrual Period
Number of Pregnancies
Pregnancy Complications
Delivery Complications
Living Children
Abortions/Miscarriages
Last Papsmear
Menopausal Symptoms
22
Q

Extremities/Musculoskeletal

A 
Intermittent Claudication
Varicosities
Decreased Strength
Decreased ROM
Joint Swelling/ redness
Joint Stiffness/pain
H/O Bone/Joint Infections
H/O Fractures/dislocations
H/O Back pain/disk disease
H/O Sciatica
23
Q

Neurologic

A 
H/O Concussion
H/O convulsions/seizures
H/O infections/meningitis
Mood/ Emotional Stability
Memory Loss/ Problems
Tremors
Numbness/ Sensory Loss
Paresthesia (Pins/Needles)
24
Q

Hematologic

A 
Easy Bruising
Bleeding (Gums, Skin)
H/O Transfusions
H/O Anemia
H/O Blood Diseases
25
Q

Endocrine

A 
Intolerance to Heat/Cold
Nervousness
Sleeplessness
Polyphagia/uria/dipsia
Nocturia
Tested For Diabetes
H/O Thyroid Disease

Medical History Checklist (1 decks)

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