Name Age DoB PC: List of problems Hx of each Characteristics of Pain Site: where, local/ diffuse, "Show me where

e it is worst". Onset: rapid/ gradual, pattern, worse/ better, what did when symptom began. Character: vertigo/ lightheaded, pain: sharp/ dull/ stab/ burn/ cramp/ crushing. Radiation [usually just if pain]. Alleviating factors, "What do you do after it comes on?" Time course: when last felt well, chronic: why came now. Exacerbating factors, "What are you doing when it comes on?". Severity: scale of 1-10. Associated symptoms. Impact of symptoms on life: "Does it interrupt your life". PMH: Operations - Problems with the anesthetic in surgery Admissions to hospital for serious illness Chronic illness Childhood illness Tests and treatment prescribed for these. Drugs remaining relevant: corticosteroids, OCP, antiHTN, chemotherapy, radiotherapy MJ THREADS: MI Jaundice TB HTN RF Epilepsy Asthma Diabetes Stroke Obstetric Hx: Gravidity (pregnancies) Parity (births) Complications Mode of delivery Birth weights Gynae Hx: Menarche/menopause Length of cycle, length of period LMP Smears Contraception Medication: Prescriptions OTC OCP/HRT Alternative Recreational O2, Steroids, Home Nebuliser, TPN, PEG Feeding, Dialysis

Family Hx: Current illness parent/siblings: age onset/death Parents alive? Children Congenital defects Thyroid disease Diabetes Cancer Heart problems

Social Hx: Smoking (cigarette/pipe/chew) Alcohol Birthplace Race Occupation, level of education Travel Married + health spouse Pets Social support Type of housing Diet/exercise "Is there some things that worry you about the symptoms you are having?" Psychiatric Hx: suicide attempts, counseling, violence Systems review CVS Angi na Hypertensi on SOB / PND Normal Haemopty sis PV D Oede ma Palpitatio ns Unknown Whee ze SO B

CHOLESTEROL RS Coug h Sputu m

Elevated Ches t Pain Night Sweat s

Exercise tolerance
GIT N/ V Heartbu rn Wt los s Jaundi ce Abd o Pain Bloo d PR Chan ge bowel habit s Incontinen ce

GUT Haematu ria CNS Headach es

Burni ng Blacko uts

Scaldi ng Dizzine ss

Frequen cy Weakne ss

Hesitan cy Anxie ty

Incontinen ce visio n

Endocrine Diabet Thyro es id Locomotor / Skin

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