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Patient name: ___________________ DOB ___________Sex_______ Race __________ Marital status__________ Employer ______________________Contact person ____________ Address _______________

Chief complaint(s)

Medications (name, dose, route frequency of use)


History of present illness (HPI)

Symptoms (onset, location, duration quality, quanity/severity, timing, setting in which it occurs, remitting or exacerbating factors, associated manifestations) Chronology (chronic illness)

Past Medical History (PMH) Childhood illnesses

Medical/chronic illnesses/conditions


Surgical history


(menstrual history, contraception, sexual function)

Psychiatric illnesses

Health Maintenance Data Immunizations (Tdap, HepB, HPV, Flu, Pneumovax, MMR) Sreenings Dental

Eye Gyn/mamm Testicular / rectal Travel in last year/ Military service Substance use smoking drugs alcohols Nutrition, (daily intake, caffeine, height and weight, satisfaction with with weight) Sleep (aids, pattern, enough sleep?) Exercise (frequency and type, ADLS for elders) Safety (seat belts, helmets, sunblock, smoke detectors Family History (illnesses, death/cause of death, age) (HTN, high cholesterol, CAD, stroke, DM, thyroid or renal
disease, cancer, arthritis, TB, asthma, lung disease, seizure, h/a, mental illness/suicide, alcohol/drug addictions, allergies)

parents, grandparents siblings children/grandchildren

Personal/Social History country of origin job/schooling (highest education, occupational history)

friends (satisfaction?, activities) finances (source of income, dependents, healthcare coverage) living/family situation (home situation/members, who makes decisions, pets,
weapons, smokers)

Lead exposure/work exposure

Review of Systems (ROS)

General (fever, chills, weakness, malaise, fatigue) Skin (itching, dryness, rashes, lumps, color changes, masses) Nails (changes in texture, appearance) Head/face (headaches, facial pain, dizziness)

Eyes (current vision, glasses/contacts, vision changes, pain/redness, discharge, photophobia)

Ears (hearing, tinnitus, discharge, vertigo, pain) Nose/Sinuses (frequent colds, stuffiness, bleeding, itching, discharge)

Mouth/ Throat (teeth/gums, sore throat, voice changes, dental care) Neck (stiffness/pain, masses, tenderness) Breasts (changes, masses/swelling, pain/tenderness, discharge, self exam) Respiratory (cough, sputum, dyspnea, wheezing, xray?) CV (chest pain, EKG, palpitations, orthopnea) GI (appetite, food intolerances, dysphagia, heartburn, n/v, bowel movements/changes/bleeding, constipating/diarrhea, abd pain, belching) GU (frequency of urination, urgency, pain, hematuria, UTIs, stones, incontinence, burning on urination)

Reproductive (male) (discharge, hernias, testicular pain/masses, sexual patterns,

impotence, ED)

Reproductive (female) (age of menarche, periods, spotting, LMP, menopause,

discharge,itching, pregnancies, birth control methods, sexual patterns, problems with libido, sexual abuse)

Peripheral vascular (cramps, varicose veins, thrombophlebitis, edema) Muskuloskeletal (muscle/joint pain/tenderness, swelling, stiffness, limitations, assistive

Neuro (fainting, seizures, weakness, memory loss) Hematologic (easy bruising/bleeding, anemia) Endocrine (heat/cold intolerance, excessive sweating, thirst or hunger) Psychosocial history Self concept (strengths/weaknesses, change, goals/values/future) Stress (sources, coping


Head Hair Eyes Ears Nose Mouth Lymph Neck Chest/Lungs Cardiovascular Abdomen Muskuloskeletal Neuro