history checklist

8/4/2019 History Checklist

1/10

History ChecklistDate:___________Time:_________

Patient InfoName

Age

DOB

Gender

Race

Birthplace

Occupation

Source of Info

Source

Reliability

Religion

Mental Status Oriented to Name? Time/Date? Place?

Chief Complaint (x how many days?): I am here for a well-checkup. My last one was __________________

History of Present Illness

Last well-checkup

Blood work (CBC; liver, kidney, and thyroid function test;

cholesterol test; c-reactive protein; ferritin blood level)Chest X-ray and CAT scans

EKG

Stress testing (if pt over 40yo)

Basic spirometry (if pt smokes or smoked w/in 5y)

Flexible sigmoidoscopy with Barium enema (if pt over 40yo)

Eye exam- glaucoma screening and fundoscopic exam

Immunizations (pneumonia shots, tetanus, hepB, etc)

MEN: rectal and prostate exam

MEN: PSA level (if pt over 40yo)


2/10

WOMEN: breast exam

WOMEN: pelvic exam and PAP smear

Notes:

Allergies

Type: Meds, Food, Environment, Insects,

Chemicals, Dander

When last allergic reaction occurred What happened

Notes:

Medications

Type:

Rx, OTC, herb,

home remedy

Name of

Medication

Physician Dosage Frequency How the

med is

taken

Reason for the

med

How long the me

has been taken

Notes:


3/10

Past Medical HistoryChildhood Illnesses When/Age Complications

Measles

Mumps

Rubella

Chicken Pox

Pertussis

Strep Throat

Other

Notes:

Adult Illnesses Condition Date of Diagnosis Name of Health Provider Treatment (Rx)

Notes:

Past Hospitalizations Where (city, state,

hospital)

Date Diagnosis Name of

Physician

Treatment (Rx) Complications

Notes:


4/10


5/10

Tobacco

Illicit Drug Use

Notes:

Family HistoryRelationship Alive or Deceased Age Medical History

Paternal Grandfather

Paternal Grandmother

Maternal Grandfather

Maternal GrandmotherFather

Mother

Sibling

Sibling

Sibling

Sibling

Notes:


6/10

Review of Systems

General Recent weight gain/loss Clothes fit tighter/looser than before Weakness, fatigue, fever

Skin Rashes Lumps Sores Itching Dryness

Color change Changes in hair or nailsHEENT

Head Headache Injury Dizziness Lightheadedness

Eyes Vision Glasses/contacts Last eye exam Pain Redness Excessive tearing Double vision Blurred vision Spots Specks

Flashing lights Glaucoma Cataracts

Ears Hearing Tinnitus Vertigo Earaches Infection Discharge Hearing aids


7/10

Nose and sinuses Frequent colds Nasal stuffiness Discharge Itching Hay fever Nosebleeds Sinus trouble

Throat/Mouth Condition of teeth Gums Bleeding gums Dentures Last dental exam Sore tongue Dry mouth Frequent sore throats Hoarseness Voice changes

Neck Lumps Swollen glands Goiter Pain Stiffness in neck

Breasts Lumps Pain or discomfort Nipple discharge Self-examination practices Date of last mammogram

Respiratory Cough Sputum

o Coloro Quantity

Hemoptysis Dyspnea

Wheezing Pleurisy Last chest x-ray Asthma Bronchitis Emphysema pneumonia Tuberculosis

Cardiovascular Heart trouble High BP Rheumatic fever Heart murmurs Chest pain or discomfort Palpitations Dyspnea Orthopnea Paroxysmal nocturnal dyspnea Edema

Past EKG Past Stress Test


8/10

GI Trouble swallowing Heartburn Appetite Nausea Bowel movements Color and size of stools Change in bowel habits Rectal bleeding Black or tarry stools Hemorrhoids Constipation Diarrhea Abdominal pain Food intolerance Excessive belching or passing of gas Jaundice Live or gallbladder trouble Hepatitis

Urinary Frequency of urination Polyuria Nocturia Urgency Burning or pain on urination Hematuria Urinary infections Kidney stones Incontinence Males

Reduced caliber or force of urinarystream, Hesitancy, Dribbling?

Genital

Males Hernias Discharge from or sores on penis Testicular pain or masses Sexually active History of STDs

o Treatments Sexual habits

o Interesto Functiono Satisfaction

Birth control methods Condom use Exposure to HIV infection Last rectal exam Last prostate exam

Female Periods Regularity Frequency Duration

Bleeding b/t periods or after intercourse Last menstrual period Dysmenorrheal (pain during menstruation) Premenstrual tension Menopausal symptoms Postmenopausal bleeding Exposure to diethylstilbestrol (DES) during

pregnancy


9/10

Vaginal Discharge Sores Itching Lumps Sexually active

STDs and treatments Number of pregnancies (See past medical

history)

Birth control methods Sexual preference

o Interesto Functiono Satisfaction

Dyspareunia Exposure to HIV infection Last PSA levels

Peripheral Vascular Intermittent claudication Leg cramps Varicose veins Past clots in veins

Musculoskeletal Muscle or joint pains Stiffness Arthritis Gout Backache Swelling Redness Pain Tenderness Limitation of motion or activity Timing of symptoms/Duration

Neurologic

History of trauma Fainting Blackouts Seizures Weakness Paralysis Numbness or loss of sensation Tingling or pins and needles Tremors

Hematologic Blood type Anemia Easy bruising or bleeding Past transfusions

Endocrine Thyroid problem Heat or cold intolerance


10/10

Excessive sweating Excessive thirst or hunger Polyuria Change in glove or shoe size Sudden weight gain/loss

Psychiatric Nervousness Tension Mood Depression Memory changes Suicide attempts Mental health professional

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