History Checklist

Date:___________Time:___________

Patient Info
Name Age DOB Gender Race Birthplace Occupation Source of Info Source Reliability Religion Mental Status Oriented to Name?

Time/Date?

Place?

Chief Complaint (x how many days?): I am here for a well-checkup. My last one was __________________ History of Present Illness
Last well-checkup Blood work (CBC; liver, kidney, and thyroid function test; cholesterol test; c-reactive protein; ferritin blood level) Chest X-ray and CAT scans EKG Stress testing (if pt over 40yo) Basic spirometry (if pt smokes or smoked w/in 5y) Flexible sigmoidoscopy with Barium enema (if pt over 40yo) Eye exam- glaucoma screening and fundoscopic exam Immunizations (pneumonia shots, tetanus, hepB, etc) MEN: rectal and prostate exam MEN: PSA level (if pt over 40yo)

WOMEN: breast exam WOMEN: pelvic exam and PAP smear Notes:

Allergies Type: Meds, Food, Environment, Insects, Chemicals, Dander

When last allergic reaction occurred

What happened

Notes:

Medications Type: Rx, OTC, herb, home remedy

Name of Medication

Physician

Dosage

Frequency

How the med is taken

Reason for the med

How long the med has been taken

Notes:

Past Medical History

Childhood Illnesses Measles Mumps Rubella Chicken Pox Pertussis Strep Throat Other Notes: When/Age Complications

Adult Illnesses

Condition

Date of Diagnosis

Name of Health Provider

Treatment (Rx)

Notes:

Past Hospitalizations

Where (city, state, hospital)

Date

Diagnosis

Name of Physician

Treatment (Rx)

Complications

Notes:

Surgeries

Where (city, state, hospital)

Physician

Date

Purpose

Outcome

Complications

Notes:

Immunization History
Vaccines Childhood Annual Flu Shot Pneumovax Hepatitis B TB Varicella Tetanus Other Notes: Yes No Does Not Recall

Personal and Social History

Marital Status Children Living Conditions Diet Exercise Occupation Education Military History Leisure Activities/Hobbies Alcohol

Tobacco Illicit Drug Use Notes:

Family History
Relationship Paternal Grandfather Paternal Grandmother Maternal Grandfather Maternal Grandmother Father Mother Sibling Sibling Sibling Sibling Notes: Alive or Deceased Age Medical History

Review of Systems
General Recent weight gain/loss Skin HEENT Head Eyes Clothes fit tighter/looser than before Weakness, fatigue, fever

Rashes Lumps Sores Itching Dryness Color change Changes in hair or nails

Headache Injury Dizziness Lightheadedness Vision Glasses/contacts Last eye exam Pain Redness Excessive tearing Double vision Blurred vision Spots Specks Ears Flashing lights Glaucoma Cataracts

Hearing Tinnitus Vertigo Earaches Infection Discharge Hearing aids

Nose and sinuses Frequent colds Nasal stuffiness Discharge Itching Hay fever Nosebleeds Sinus trouble

Respiratory Cough Sputum o Color o Quantity Hemoptysis Dyspnea Wheezing Pleurisy

Throat/Mouth Condition of teeth Gums Bleeding gums Dentures Last dental exam Sore tongue Dry mouth Frequent sore throats Hoarseness Voice changes

Last chest x-ray Asthma Bronchitis Emphysema pneumonia Tuberculosis Cardiovascular Heart trouble High BP Rheumatic fever Heart murmurs Chest pain or discomfort Palpitations Dyspnea Orthopnea Paroxysmal nocturnal dyspnea Edema Past EKG Past Stress Test

Neck Lumps Swollen glands Goiter Pain Stiffness in neck Breasts Lumps Pain or discomfort Nipple discharge Self-examination practices Date of last mammogram

GI Trouble swallowing Heartburn Appetite Nausea Bowel movements Color and size of stools Change in bowel habits Rectal bleeding Black or tarry stools Hemorrhoids Constipation Diarrhea Abdominal pain Food intolerance Excessive belching or passing of gas Jaundice Live or gallbladder trouble Hepatitis Urinary Frequency of urination Polyuria Nocturia Urgency Burning or pain on urination Hematuria Urinary infections Kidney stones Incontinence Males Genital

Reduced caliber or force of urinary stream, Hesitancy, Dribbling?

Males Hernias Discharge from or sores on penis Testicular pain or masses Sexually active History of STDs o Treatments Sexual habits o Interest o Function o Satisfaction Birth control methods Condom use Exposure to HIV infection Last rectal exam Last prostate exam Female Periods Regularity Frequency Duration Bleeding b/t periods or after intercourse Last menstrual period Dysmenorrheal (pain during menstruation) Premenstrual tension Menopausal symptoms Postmenopausal bleeding Exposure to diethylstilbestrol (DES) during pregnancy

 Vaginal Discharge Sores Itching Lumps Sexually active STDs and treatments Number of pregnancies (See past medical history) Birth control methods Sexual preference o Interest o Function o Satisfaction Dyspareunia Exposure to HIV infection Last PSA levels Peripheral Vascular Intermittent claudication Leg cramps Varicose veins Past clots in veins Hematologic Blood type Anemia Easy bruising or bleeding Past transfusions Endocrine Thyroid problem Heat or cold intolerance

Musculoskeletal Muscle or joint pains Stiffness Arthritis Gout Backache Swelling Redness Pain Tenderness Limitation of motion or activity Timing of symptoms/Duration Neurologic History of trauma Fainting Blackouts Seizures Weakness Paralysis Numbness or loss of sensation Tingling or pins and needles Tremors

 Excessive sweating Excessive thirst or hunger Polyuria Change in glove or shoe size Sudden weight gain/loss Psychiatric Nervousness Tension Mood Depression Memory changes Suicide attempts Mental health professional