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Appendix A.

THE MEDICAL HISTORY (for new patient)


I. Chief Complaint -- The chief complaint should include the presenting problem/concern in the patients' own words, accompanied by the duration of the complaint. II. History of Present Illness -- In addition to providing a detailed and thorough discussion of the chief complaint, this section should also provide a "thumbnail sketch" of the patient and his/her significant underlying medical problems. It is often quite useful to include patient age, sex, race, occupation, and potentially relevant underlying chronic diseases in the history of present illness. III. Past Medical History A. Allergies --This section should discuss briefly all allergies, including the prior reaction to each allergin (i.e., "rash"): Medication, Foods, Dust, pollen, and plants, Animals B. Current Medications -- Both prescription and nonprescription medications with indications and dates (such as vitamins, analgesics, etc.), should be discussed in this section C. Birth and Development D. Communicable Diseases E. Immunizations F. Injuries Broken bones/fractures, Sutured lacerations G. Surgery -- This section should include dates, procedures, locations, and complications of the procedures (if any) H. Hospitalizations -- All discussed hospitalizations should include dates, illnesses, durations, and hospital locations I. Past Medical Care -- Please include current physicians and the dates the patient was last seen by health care professionals J. Occupation Exposures -- Please include exposures to dusts, heavy metals, radioactivity, asbestos, etc. incurred because of employment and hobbies K. Radiation Exposure -- Be sure to include exposure to therapeutic radiation L. Smoking History M. Alcohol Intake N. Chronic Diseases O. Miscellaneous P. Family History--This section should include data pertaining to the significant illnesses (both past and present) of the genetically related relatives of the patient, and should utilize genealogy-tree format when appropriate. Q. Social History--Please include marital/family background, living arrangements, support systems, education, occupational background, religious affiliations, hobbies/other interests, etc. Also, briefly discuss the daily routine of the patient along with a dietary history, sleep habits, exercise, advanced directives. Review the use of seat belts and sunblock. Ask about guns in the home and smoke detectors) R. Medical Screening Tests (PPD skin test, Chest X-ray, Cholesterol, PSA (male), Pap smear (female), Self-breast exam (female), Mammogram (female), Tetanus, Colonoscopy)

Refer to Review of Systems material which follows in Appendix B to complete the patient history. Also see the Sample Medical History handout for a good example of a complete patient write-up.