CMA Quizlet - Patient Intake

Problem list

list of major problems facing the patient that may be contributing to the patient's medical condition; problems can include: physical symptoms, social, emotional, or financial difficulties

Past medical history

history of medical conditions that the patient currently has or has had diagnosed in the past

Current medications

list of current prescription and over-the-counter medications (including vitamins and herbal supplements) that the patient is taking; it is important to include the dosage, the frequency, and the route of administration (oral, subcutaneous, suppository, etc.)

Allergies

allergies to medications and non-medications and the reaction when exposed to the allergen

Family history

any medical conditions that have been diagnosed in immediate blood relatives; it is important to include any genetic conditions such as hemophilia which can be passed down through family members

Surgical history

any prior surgeries that the patient has had including the date of surgery and laterality (right vs left vs bilateral) when applicable

Social history

includes current employment, sexual activity, alcohol intake, illicit drug use, or exercise

Normal Vital Signs - Blood Pressure

90/60 mm Hg to 120/80 mm Hg

Normal Vital Signs - Breathing

12 to 20 breaths per minute.

Normal Vital Signs - Pulse

60 to 100 beats per minute

Normal Vital Signs - Temperature

97.8°F to 99.1°F (36.5°C to 37.3°C); average 98.6°F (37°C)