Patient Care - History

Student Doctor:  1 2 3 4 Date: 6/18/2008 Evaluator: Patient's Answer

Do or ask the following:
Introduce self Greet patient by LAST name Sit down for interview Open ended question about chief complaint (eg. "What brings you in today?
What can I do for you today?")

History of Present Illness 5 6 7 8 9 10 11 12 13 14 Onset (when did it start?) Position (where is it located/ best felt?) Provoking factors (What triggers it?) Palliating factors (What makes it better?) Quality (What type?? Describe the pain) Radiation (Does it travel or move?) Severity (On a scale of 1 – 10,) Timing (When does it occur/recur?) Duration (How long does it last?) Associated symptoms: Asked about the following: 15 Yes Have you had... 16 19 20 21 22 23 25 26 27 28 29 Medication (name, dose, route, frequency of use) Allergies Tobacco Use (reported in pack-years) Alcohol Use (CAGE Questionnaire, if warranted) Use of illicit drugs Past Medical History (any hospitalizations or illnesses?) Childhood Illnesses Adult Illnesses (Medical, surgical, Ob/Gyn, psychiatric) Health Maintenance (Immunizations, screening tests) Family Medical History Personal/Social History Ask about work, education, lifestyle habits, diet, ADLs (activities of daily living), religious affiliation 30 Review of Systems (ALL systems that were not covered in the HPI) No 18 Communication Skills 31 Maintained a professional demeanor 17

32 33 34 Showed compassion and/or makes patient feel comfortable Gathered information efficiently Answered patient questions (Do you have any questions?) Comments .

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