Patient History Questions
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Patient History Questions: Identifying Data: Age, Gender, Marital Status Chief Complaint: What brought you to the hospital? HPI: When did it start? Where did it start (physically)? What does it feel like (characterize pain)? Can you rate pain on scale of !"? #o$ often, #o$ long, #o$ %any? What setting did this occur (surrounding en&iron%ent'contet)? oes anything %ake it $orse'better? id you notice anything associated $ith pri%ary sy%pto%? Medications- What %eds? What dose? What route? What fre*uency? Supple%ents? +irth Control? #erbals'+otanicals? Allergies- Are you allergic to any %edications'e&er had a reaction to any %edication? Any food'en&iron%ental Allergies? Tobacco/Alcohol/Drugs- (Can be asked here or in personal'social h) o you s%oke? #o$ long? #o$ %uch? #o$ often? Can you tell %e about your drinking habits? o you use illicit drugs? Past History: Childhood- id you ha&e any %aor childhood illnesses (%u%ps'%easles'chicken po)? Any chronic childhood illnesses? Adult- Medi cal- #a&e you been dia gno sed $it h a ny il lnes ses a s an adu lt (dia bet es, hypertension, hepatitis etc.)? Surgic al- Can y ou t ell %e a bou t a ny %a or s ur gerie s y ou/ &e had? When? 0or $hat? What type of operation? 1b'Gyn- Any pregnancies? Can you tell %e about your %enstruation history? 1nset, describe cycle? #o$/s your s eual function? 2syc hiatri c- Any hist ory of psychi atric illn ess? (iag nosis , hospit aliza tion, treat%ent) #a&e you gotten your i%%unizations (tetanus, polio etc)
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3b, 2ap s%ear, %a%%ogra%, cholesterol?
Family Hx:Can you tell a bit about your father/s health (age, or cause of death)? iagnosed$ith anything?
#o$ bout your %other?+rothers?Sisters?Grandparents?Grandchildren?Any history of hypertension, stroke, diabetes, thyroid'renal disease? Arthritis, 3+,4ung disease, %ental illness (suicide), substance abuse?
Personal/Social History:What do you do for a li&ing?#o$ far along in school did you get?
What is it like at ho%e? Any significant others? #o$ is the relationship?Any significant sources of stress (i%%ediate' on!going)?5eligious'spiritual beliefs?Acti&ities of aily li&ing (especially elderly)?
o you e ercise %uch?What is your usual daily food intake? Caffiene?Any alternati&e health care?
Re ie! of Systems "#ons of $uestions% Start &road'()arro! it Do!n*:General- What is your usual $eight? #a&e you had significant loss'gain?
Any recent $eakness, fatigue, fe&er?
Skin- #a&e you noticed any changes in your skin (rash, sores, lu%ps)?
HEENT- #ead- #o$/s the old noggin? Any headaches, dizziness, light!headedness?
6yes- #o$ is your &ision? Any changes? Any pain, redness,double'blurred &ision? What about glauco%a7 any cataracts?
6ars- #o$ is your hearing? Any changes? Any ringing, earaches,infection? o you use hearing aids?
8ose- o you ha&e any nasal'sinus trouble? 0re*uent colds, stuffiness,nosebleeds, hayfe&er?
3hroat-#o$ is your teeth and gu%s? When $as the last ti%e you $ent tosee the dentist? Any soreness' sores? Sore!throats?
Neck- #o$ is your neck, any recent pain or stiffness? Breasts- #a&e you noticed any recent abnor%al changes in your breasts? 2ain,
lu%ps, discharge? Respirator - #o$ is your breathing'lungs? #a&e you had any recent trouble? Any
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