Name / Age

CC
AVS

Red Flags???
Counseling (TADS DEC):
T

HPI

(O)

(R)

Sx

Diet/Ex

I
P
Q
O

R
M
P

A
F
A
N

SOB

D/C

HA

Sx
S
L

CP

PE

O
T

Ur

BM

MSK

S
A
W
E
D
DDx (esophagitis, 2ndary syphilis, )
1.
2.
3.
4.
5.

A
D
P
A
Tests (MSE, PE, pelvic, genital, rectal)
1.
2.
3.
4.
5.

Comp

Name / Age
CC
Abnormal VS

Red Flags???
Counseling (TADS DEC):
Tobacco Alco Drugs

HPI

OB/GYN

Location

ROS

Sex Diet/Ex

Intensity
PMH
Quality
Onset

Allergies

Radiation
Meds
Prev Eps?

Progression

Freq

Const/Intermit

Associated Sx

Hospitalizations / PSH

Alleviation
Family Hx
Aggravation
Nausea

Vomit

Diarrh/Constip Dizzy

HA

Fever Cough SOB

Sexual Hx
Social Hx
Live with?

CP

Palp

PE
Occupation

Ur

BM

Tobacco
Alcohol

Jt pain MSK
Drugs
Travel Trauma
Sleep
Appetite
Weight
Exercise
DDx (esophagitis, 2ndary syphilis, )
1.
2.
3.
4.
5.

Psych (Dementia)
Diet

Abuse
Tests (MSE, PE, pelvic, genital, rectal)
1.
2.
3.
4.
5.

Compliance