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Gender identity
Ask pronouns
Reason for seeking care
healthy- ask general questions; ill- focus on the issue
History of Present Illness
OLD CARTS
Onset
Location
Duration
Characteristics
Aggravating
Related symptoms
Treatment
Severity
Social Determinants of Health (5?)
Economics stability, Access to quality education, social and community aspects, access to and quality of health care, and the neighborhood and built environment in which the client works and lives.
Medical history
Childhood illnesses
injuries
chronic illnesses
hospitalizations
surgeries
immunizations
health exams and screenings
allergies
medication reconciliations
Nutrition
Obstetrical:GTPAL

GTPAL
gravida (number of pregnancies), term (number of full-term births), preterm (number of preterm births), abortion (number of abortions), and living children.
Emotional and Psychological
Stress? Support systems? therapist?
Family history
immediate family have genetic disorders, heart attacks, kidney failure