Medical History Checklist Flashcards
1
Q
Categories/headings in order
26
A
Introductions/Personal Information Chief Complaint HPI PMH FH Social History REVIEW OF SYSTEMS General Skin Head Ears Eyes Nose/Sinuses Mouth/Throat Neck Lymph Nodes Breasts Respiratory Cardiovascular Gastrointestinal Genitourinary OB/GYN Extremities-musculoskeletal Neurologic Hematologic Endocrine Psychiatric
2
Q
Checklist for History of Present Illness
8
A
Onset: date/time/duration Provocative Palliative Quality Quantified Regionality Radiation Associated symptoms
3
Q
Checklist for Past Medical History
8
A
General Health Chronic illnesses Surgical procedures Hospitalizations Injuries/major illnesses Medications Allergies and reaction Immunizations
4
Q
Checklist for Family history?
8
A
Cancer Hypertension Heart disease Diabetes Stroke Seizures Bleeding disorders Age/health of parents and grandparents
5
Q
Checklist of Social History?
15
A
Occupation Education Living situation Diet Physical activity Caffeine use Alcohol use Tobacco use Sexually active Monogamous/# of partners Prescription drug abuse Illicit drug abuse Military history Safe at home Travel
6
Q
General Review of Systems
6
A
Weight changes Fatigue Malaise Fever/Chills Sweats/Night sweats Weakness
7
Q
Skin
5
A
Rashes/sores/lesions Lumps/masses Pruritis/itching Dryness/moisture Hair/nail changes
8
Q
Head
4
A
Headaches
Head Trauma
Dizziness/vertigo
Syncope/LOC/concussion
9
Q
Ears
5
A
General hearing status Otalgia (earaches) Past infections Drainage/discharge Tinnitis
10
Q
Eyes
6
A
General vision status Glasses/contacts Last eye exam Pain/redness/tearing Diplopia/blurriness H/O trauma/foreign bodies
11
Q
Nose/Sinuses
6
A
Sinus pain Epistaxis Nasal congestion Nasal drainage Frequent colds Sneezing
12
Q
Mouth/Throat
5
A
Dental hygiene Toothaches Last dental exam Pain/soreness Hoarseness
13
Q
Neck
3
A
Pain
Stiffness/limited ROM
14
Q
Lymph Nodes
2
A
Tenderness
Enlargements
15
Q
Breasts
4
A
Pain
Lumps/masses
Nipple changes/discharge
Self-exam
