CC: Age, Gender, Complaint, Time Occurring

HPI: Detailed Description of CC

 Onset of Symptoms (Context & Location)

 Triggers/Causes of Symptoms
 Quality & Intensity of Symptoms
 Course (Sudden, Gradual, Constant, On/Off)
 Duration of Symptoms
 Associated Symptoms
 Factors that Improve or Exacerbate Symptoms

PMH:

 Childhood Illnesses
 Major Adult Illnesses
 Past Surgical History
 Past Hospitalizations/Transfusions
 Past Medications
 Allergies
 Immunizations

Family History: History of Disease in 1st & 2nd Degree Blood Relatives

Social History: Occupation, Social Support, Diet/Exercise, Sleep, Stressors, Sexual History, Drugs/Alcohol

ROS

 General: Fever, Fatigue, Appetite, Sleeping

 Eye: Changes in Vision, Photophobia, Pain, Redness, Glaucoma/Cataracts
 H&N: Headache, Neck Pain/Stiffness, Head Injury
 ENT:
o E: Hearing Loss, Ringing?
o N: Nosebleeds, Post Nasal Drainage
o T: Changes in Taste, Changes in Voice, Sore Throat, Halitosis
 Cardiovascular: Chest Pain, Palpitations, Dyspnea, Syncope, Peripheral Edema, Cytanosis
 Respiratory: Cough, Sputum Change, Difficulty Breathing
 Gastrointestinal: Nausea, Vomiting (Bloody), Dysphagia, Abdominal Pain/Distention, Jaundice,
Changes in Bowel Movement, Changes in Stool Appearance
 Genitourinary
o Genital
 M: Dyspareunia, Penile Discharge/Bleeding, Genital Lesions/Masses/Pain, STDs
 F: Dyspareunia, LMP, Irregular Menses, Contraception, Vaginal Discharge,
Genital Lesions
o Urinary: Changes in Urination Frequency/Production, Dysuria, Nocturia, Hematuria
 MSK: Muscle/Joint Pain, Joint Swelling/Inflammation, Muscle Weakness/Atrophy, Back Pain
 Integumentary: Pruritus, Burning, Rashes, Lumps, Pigmentation, Hair Loss/Gain, Changes in Nails