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Signs and symptoms
Signs are findings you can see, feel, hear, or smell
Symptoms are feelings that the patient must tell you
Allergies
any allergies to medications, including prescription Rx and over-the-counter meds
Medications
Any medications the patient takes regularly
Past Pertinent History
Any relevant past medical history
any condition the patient takes medication to treat
any history similar to the current chief complaint
Last oral intake
Most recent food and fluid intake
Events
What events led up to the chief complaint?