Patient History Flashcards
Identifying Data
Name Age Race DOB DOS Sex
Chief Complaint:
patient problem
History of Present Illness:
Onset
Location
Duration
Character Aggravating Factors Relieving Factors Time/frequency Severity
Onset
Progression
Quality
Radiation
Medications
Effect on Life
Associated symptoms
Treatments
Prior symptoms
Exposure
Past Medical History:
Pregnancy
Allergies/sensitives
Transfusion
Medications Immunizations Medical History Injury Childhood diseases Surgical
Allergies/Sensitivities:
meds and what happened,
other severe rxn’s e.g. bees, nuts
Medications:
name, strength, frequency, route, OTC’s, CAM’s
or FRONCS
Medical History
Hospitalizations/cardiac
Anemia
Vascular
Endocrine/thyroid/diabetes
GI/GERD/PUD
Allergies
Skin
Bowel Liver Asthma / COPD Seizures Tropical/parasite
CVA Hypertension Arthritis Infections/STD/TB Renal
Surgical:
diagnosis, date, outcome, complications, hospitalizations
Childhood Diseases
measles, Rubella, mumps, chickenpox, pertussis, diphtheria, rheumatic fever, polio
Immunizations:
childhood, hepatitis B, flu vac, Pneumovax, tetanus, Tdap, Zostavax
Injuries:
type, treatment, disability
Transfusions:
reactions, antibodies
Pregnancy
complications of pregnancy
Gravid (# of pregnancies),
Parity (# of kids),
Abortions (spontaneous/surgical),
Family History
Gout Renal Allergies Mental illness Migraine Anemia/blood disease/sickle cell
Cancer (type)
CVA
Cystic Fibrosis
Hypertension
Arthritis
Diabetes
Vascular
Dementia
Glaucoma Hearing/visual Other Seizures TB
Cardiac/MI
Asthma/COPD
Thyroid
STD
Social History
Hobbies
Education
Legal
Pets
Military
Exercise
Diet
Stress
Family
Occupation
Religious
Culture Habits (caff, tob, IV/illicit Drugs) Exposure Sexual Travel
