Name

L: O: D: I: Q: F: T: R: A: A: A: P: Location Onset Duration

yo

Sex

CC
ROS for adults T: H: E: N: Trauma Headache Eye, Ear, Edema Nausea ROS for child F: E: V: E: R: FN: Fever, Night sweats R: Racing of heart, Rash C: C: S: Chest pain, Cough SOB C: U: D: A: F: Abdominal pain Fatigue D: S: S: P: U: B: Pain in joints Urinary Bowel W: H: A: S: A: W: D: Sleep Appetite Weight Dizziness DC: Development Check I: M: Bi: Immunization Motor/verbal development Birth history T: Weight Height Appetite Trauma, Travel Conscious Cough Urination Diarrhea Dehydration Seizure Sleep S: Fever Ear pulling / discharge Vomiting Eye discharge Rash SOB

Intensity 1-10 Quality Frequency Timing Radiation Associated symptoms Aggravating factor Alleviating factor Progression

General history P: A: M: Previous episodes of CC Allergies Medication

History H: Hospitalization I: Illnesses T: Travel B: Blood transfusion S: Surgery S: Sick contact F: O: S: Family history Ob/Gyn Sexual history

S:

Social history

W: Work H: Home (who do you live with?) A: Alcohol T: Tobacco

R: Recreational drugs E: Exercise D: Diet

Sign up to vote on this title
UsefulNot useful