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How do you do a quick assessment, diagnosis, and treatment of a conscious patient? What is the gender of the patient? How old is the patient? |
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Source and Reliability Identifying Data and Source of the History Who informed you? What seems to be the problem? Do you feel this is a new medical problem? On what date are you writing this document? Where is the patient on the date you are writing this document? Where is he at this point as of March 10, 2011? Who is writing this document? Patient Relative Secretary Referring medical doctor Social service Police Court If other, please specify |
| Patient Profile and History |
| Social History |
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Are you on a special diet? Do you have any chronic condition like hypertension, diabetes, asthma, etc.? What was the indication of medication? Were you ever hospitalized? What was the indication? How do you commute? Do you need any assistance? Why do you need assistance? What is your eyesight number? Who gave you this eyesight number? How did they calculate this number? Did you ever have any surgery? When and where did you have the surgery? What was the procedure? Where are the surgical notes? Where are you located now? Do you ever feel unsafe where you live? |
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Chief Complaint(s) What is the main reason for your visit today? How long does the problem last? Is anything else occurring at the same time? Yes__ No__ If yes, please explain. Nausea__ Rash__ Headache__ Other__ Is the problem constant or variable? When did you first notice the problem? 2 days ago__ 2 weeks ago__ 1 month ago__ Other__ Does anything help or make the problem worse? Moving around__ Standing__ up Lying on side__ Other__ Does the problem interfere with your normal functions? Are you on any medications? Are you on a special diet? Do you have any chronic condition like hypertension, diabetes, asthma, etc.? Were you ever on any medication for more than one week? What was the indication of medication? Were you ever hospitalized? What was the indication? How do you commute? Do you need any assistance? Why do you need assistance? What is your eyesight number? Who gave you this eyesight number? How did they calculate this number? Did you ever have any surgery? When and where did you have the surgery? What was the procedure? Where are the surgical notes? |
| Present Illness |
| Personal Health History |
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Past History What questions should you ask regarding past medical history? Do you have any past medical diagnosis and treatment? What was the diagnosis and treatment? Who, where, and when did he or she diagnose and treat you? Do you think he/she diagnosed and treated you correctly? Did the diagnosis and treatment improve your medical condition? Do you have any chronic diseases, such as heart disease, or health conditions such as high blood pressure, cholesterol or diabetes? Have you had any other serious diseases, such as cancer or stroke? How old were you when you developed these diseases? What treatments have been tried for this problem? Food Do you have enough food? What food do you eat every day? What is your favorite food? How many meals do you have each day? How long do you wait between two meals? |
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Medications Are you on any medications? Were you ever on any medication for more than one week? Do you take medications prescribed by a doctor? What medications do you take that are prescribed by a doctor? What medications do you take every day? What medications are you supposed to be taking, but aren't? What medications are you taking in a way that is different from how you were told to take them? What medications do you take? What other medications are you taking? |
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Allergy Does the patient have any known medical allergies? |
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Family History What questions should you ask in a family medical history? Do you have any brothers and sisters? How many brothers and sisters do you have? Where are they located? Family Health History Q: What is family history? A: Family history refers to health information about you and your close relatives. What diseases did your deceased relatives have? How old were they when they died? What caused their deaths? What is your family ancestry? What state, region, and continent did your mother and father come from? What was the religion of your mother and father? |
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What are the relevant questions you need to ask? Do you have any problem as of today? Is there any issue that you think is a problem? Have I seen you face to face? What do you look like? Can you forward a recent photograph? When and where was the photograph taken? My goals are that a person should live up to at least 90 years without any disability. Who from your family or relatives should be contacted in case of an emergency? |