Comphrehensive health history

Identifying data

D&T, DOB, Patient Initials, Gender, Occupation, Marital Status, Emergency Contact, Source

Emergency Contact

First name, relationship, phone number

CC

less than 3 words

HPI

OLDCART

OLDCART

Onset, location, duration, characteristics, associated manifestations, relieving factors, treatment

CHS

other than (blank) how have you been health-wise

PH

Allergies, medication, immunizations, childhood illnesses, past adult illnesses, accidents, past hospitalizations, past surgeries

Allergies

Rx, OTC, food, environment, reaction

Medication

OTC, Rx, Herbal

Immunization

Tdap, covid, mmr, varicella, hpv, hepatitis b

Childhood illnesses

chicken pox, diphtheria, measles, mumps, rubella, whooping cough, polio

Adult illnesses

ever diagnosed, what, when, treatment

accidents

any injury/accident, when, residual problems

past surgeries

type, date

FH

heart disease, lung disease, cancer, hypertension, diabetes, gastrointestinal disorder, arthritis, neurologic disease/seizure disorder, obesity, mental health, genetic disorder

Heart disease

myocardial infarction, heart failure

lung disease

tb, asthma, copd

gastrointestinal disorder

ulcerative colitis, crohns disease

Review of symptoms

integumentary, head, eyes, ears, nose & sinuses, mouth & throat, neck, respiratory, cardiovascular, peripheral vascular, breast & axillae, gastrointestinal, female reproductive, urinary, musculoskeletal, neurologic, psychiatric, endocrine, hematologic

integumentary

rashes, sores, dryness, itchiness, changes in skin color, changes in hair/nails, changes in size/color/number of moles, lumps, amount of sun exposure, use of sunscreen/spf, self skin exams, skin exam by provider

head

headaches, head injury, concussions, tbi, dizziness, lightheadedness

eyes

glasses/contacts, trouble with vision, double vision, blurry vision, pain, redness, excessive tearing, flashing lights, styes, cataracts, glaucoma, last vision test

nose & sinuses

frequent colds, nasal stuffiness, allergies, nosebleeds, sinus infections, altered sense of smell

mouth & throat

problems with teeth/gums, dry mouth, frequent sore throats, strep throat, hoarseness, thrush, dentures, partial plate, last dental cleaning exam, daily care, flossing

neck

pain, decreased rom, stiffness, swollen glands

respiratory

covid, dyspnea, cough, sputum, hemoptysis, tb testing, wheezing, asthma, pneumonia, sob

cardiovascular

heart trouble, chest pain, edema, palpitations, heart murmurs, hbp, high cholesterol, last bp check, ekg, other heart tests

peripheral vascular

changes in sensation, temperature, cramping, blood clots, swelling in legs, varicose veins

breast & axillae

lumps, lesions, dimpling, pain, tenderness, nipple discharge, bse exam by self/provider, mammogram

gastrointestinal

trouble swallowing, nausea, vomiting, heartburn, diarrhea, constipation, abdominal pain, food intolerance, hepatitis, change in appetite, weight loss/gain, describe bowel pattern, change in bowel pattern, rectal bleeding, hemorrhoids, last bowel movement, consistency/color/frequency

female reproductive

menarche, lmp, frequency, duration, quantity, dysmonorrhea, discharge, itching, sti, contraceptive/protective measures, number of pregnancies

urinary

urination elimination per day, change in pattern, incontinence, nocturia, hematuria, dysuria, kidney stones, uti, urgency

musculoskeletal

injuries, joint pain, stiffness, arthritis, decreased rom, muscle weakness, pain, backache

neurologic

memory loss, seizures, dizziness, fainting, loc, tingling, tremors

psychiatric

illness, depression, anxiety, nervousness, mood changes

endocrine

thyroid disease, diabetes, intolerance to hot/cold, excessive sweating

hematologic

anemia, easy bruising, excessive bleeding, sickle cell disease, past transfusions.

PHQ-9 Screening

have you felt down, depressed or hopeless in the last 2 weeks, have you had little interest or pleasure in doing things in the last 2 weeks

lifestyle & health practives

safety measures, risk factors

safety measures

seat belts, carbon monoxide detectors, sports helmets/padding

risk factors

tobacco, vape, alcohol, environmental hazards, marijuana, cocaine, heroin, other recreational drugs, high energy drinks

health pattern

self perception/concept, value-belief, activity-exercise, sleep-rest, nutrition, role-relationship, coping-stress-tolerance

self perception-concept

how would a friend describe you? how do you feel about your ability to handle stress? if you could change any one thing about yourself what would you change?

value-belief

what is your source of strength and hope? is religion or god significant to you? how?

activity-exercise

describe your exercise routines or activities. describe leisure and recreation activities. have you experienced any change in your activities due to your illness?

sleep-rest

at what time do you usually retire/awaken? do you feel rested? do you take any prescription or otc sleep aides.

nutrition

describe a days diet. any special diet? describe each meal and snacks including water.

role-relationship

who lives with you? describe the relationships you have with your family and friends. who provides support for you?

coping-stress-tolerance

what are the current stressors in your life? what do you do to reduce stress?