• List and describe current symptoms of chief concern and their appearance chronologically in reverse order, dating events and symptoms. • List any expected symptoms that are absent. • Identify anyone in household with same symptoms. • Note pertinent information from review of systems, family history, and personal/social history along with findings. • Where more than one problem is identified, address each in a separate paragraph, including the following details of symptom occurrence: • Onset: when problem first started, chronologic order of events, setting and circumstances, manner of onset (sudden versus gradual) • Location: exact location, localized or generalized, radiation patterns • Duration: how long problem has lasted, intermittent or continuous, duration of each episode • Character: nature of symptom • Aggravating/associated factors: food, activity, rest, certain movements; nausea, vomiting, diarrhea, fever, chills, etc. • Relieving factors: prescribed treatments and/or self-remedies, alternative or complementary therapies, their effect on the problem; food, rest, heat, ice, activity, position, etc. • Temporal factors: frequency; relation to other symptoms, problems, functions; symptom improvement or worsening over time • Severity of symptoms: quantify on a 0 (minimal) to 10 (severe) scale; effect on patient’s lifestyle • List and describe each of the following with dates of occurrence and any specific information available: • General health and strength over lifetime as patient perceives it; disabilities and functional limitations • Hospitalization and/or surgery: dates, hospital, diagnosis, complications • Adult illnesses and serious injuries • Immunizations: polio, diphtheria-pertussis-tetanus, tetanus toxoid, haemophilus influenza type b, hepatitis A and B, measles, mumps, rubella, varicella, Prevnar, influenza, anthrax, smallpox, cholera, typhus, typhoid, meningococcal, pneumococcal, bacille Calmette-Guérin, last purified protein derivative or other skin tests, unusual reaction to immunizations • Medications: past, current, recent medications (prescribed, nonprescription, complementary therapies, home remedies); dosages • Allergies: drugs, foods, environmental • Transfusions: reason, date, number of units transfused, reactions • Emotional status: history of mood disorders, psychiatric attention or medications • Recent laboratory tests (e.g., glucose, cholesterol, Pap smear, mammogram, prostate-specific antigen) • Present information about age and health of family members in narrative or pedigree form, including at least three generations. • Family members: Include parents, grandparents, aunts and uncles, siblings, spouse, children. For deceased family members, note age at time of death and cause, if known. • Major health or genetic disorders: Include hypertension; cancer; cardiac, respiratory, kidney, or thyroid disorders; strokes; asthma or other allergic manifestations; blood dyscrasia; psychiatric difficulties; tuberculosis; diabetes mellitus; hepatitis; or other familial disorders. Note spontaneous abortions and stillbirths. • Include information according to concerns of patient and influence of health problem on patient’s and family’s life: • Cultural background and practices, birthplace, position in family • Religious preference, religious or cultural proscriptions for medical care • Home conditions: economic condition, number in household, pets, presence of smoke detectors, presence and security of firearms • Occupation: work conditions and hours, physical or mental strain, protective devices used; exposure to chemicals, toxins, poisons, fumes, smoke, asbestos, or radioactive material at home or work • Environment: home, school, work; structural barriers if handicapped, community services utilized; travel; exposure to contagious diseases • Current health habits and/or risk factors: exercise; smoking; salt intake; weight control; dental hygiene diet, vitamins and other supplements; caffeine-containing beverages; alcohol or recreational drug use; response to CAGE, TACE, or RAFFT questions (see Appendix) related to alcohol use; participation in a drug or alcohol treatment program or support group • Sexual activity: protection method, contraception • General life satisfaction, hobbies, interests, sources of stress, adolescent’s response to HEEADSSS questions (see Appendix)
Reporting and Recording
Subjective Data—The History
History of Present Problem
Medical History
Family History
Personal/Social History
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Reporting and Recording
