Patient Profile

 Name
 Age
 Date of Birth

Presenting complaint
 What patient tells you is wrong

History of Present Complaint (“The gossip”)

 What is it we may do today?
 Socrates
o Site
 Where is the pain? Or the maximal site of the pain.
o Onset
 When did the pain start, and was it sudden or gradual?
 Include also whether if it is progressive or regressive.
o Character
 What is the pain like? An ache? Stabbing?
o Radiation
 Does the pain radiate anywhere? (See also Radiation.)
o Associations
 Any other signs or symptoms associated with the pain?
o Time course
 Does the pain follow any pattern?
o Exacerbating/Relieving factors
 Does anything change the pain?
o Severity
 How bad is the pain? (1-10)

Past Medical History

 JADE (General) / TAB (Respiratory) / MARCH (Cardiovascular)
o General
 Jaundice
 Anemia
 DM
 Epilepsy
o Respiratory
 TB
 Asthma
 Bronchitis
o Cardiovascular
 MI
 Angina
  Rheumatic fever
 Cholesterol
 Hypertension
 Have you had these symptoms before?
 Operations
 Drug History
o Name
o Dose
o Frequency (OD, BD)
o Root of delivery
 Allergies
o What happens when you get the allergy
 Family History
o Any conditions that run in the family that I should know about?
 Social History
o Smoke
 Amount
o Alcohol
 Amount (units/ week)
o Occupation
o Recreational Drug Use
o Activity of daily livings (ADL)
 Can they:
 Wash
 Feed
 Transfer one place to another (sit/lying)
 Mobility
 Systemic Inquiry
o CVS
 Any chest pain recently
 Palpitation
 Shortness of breath
 Syncope (fainting)
 Chest pain
o Respiratory System
 Shortness of breath
 Wheezing (high-pitched whistling sound made while breathing)
 Stridor
 High-pitched breath sound
 Hemoptysis (coughing of blood)
 Coughing
 Sputum when coughing
o GI
  Vomiting
 Diarrhea
 Loss of weight
 Loss of Appetite
 Hematemesis (Vomiting blood)
 Slime or mucus when pooping
 Change in bowl habits
 Bloating
 Strain to pass feces (Rectal tenesmus)
o Genital/ Urinary System
 Blood in urine
 Pain when urinating
 Nocturia
 Frequency
 Urgency
 Dribbling
 Hesitance
 Incomplete voiding
o Musculoskeletal System
 Morning stiffness or night
 Pain: More in the evening or at night
o CNS
 Faints
 Weakness
 Headache
 Confusion
 Slurred in speech
o Skin
 Rashes
 Ulcer
 Lumps or bumps
o Hematologic
 Anemia, easy bruising or bleeding, past transfusions and/or transfusion
reactions.
o Endocrine
 Thyroid trouble
 Heat or cold intolerance
 Excessive sweating,
 excessive thirst or hunger
 Polyuria
 Change in glove or shoe size.
o Psychiatric
 Nervousness
  Tension
 Mood, including depression
 Memory
o change, suicide attempts, if relevant.
 ICE (Ideas, Concerns, Expectation)
o Ideas
