Part 1 History and Physical Assessment
HEALTH HISTORY
Information
Present Illness (PI)
To obtain all details related to the chief complaint
Past history (PH)
To elicit a profile of the individual’s previous illnesses, injuries, or operations
REVIEW OF SYSTEMS
General—Overall state of health, fatigue, recent and/or unexplained weight gain or loss (period of time for either), contributing factors (change of diet, illness, altered appetite), exercise tolerance, fevers (time of day), chills, night sweats (unrelated to climatic conditions), frequent infections, general ability to carry out activities of daily living, behavior
Head—Headaches, dizziness, injury (specific details)
Cardiovascular—Cyanosis or fatigue on exertion, cold extremities, history of heart murmur or rheumatic fever, anemia, date of last blood count, blood type, recent transfusion