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Encounter History

Chief Complaint
1. Reason for the encounter
History of Present Illness
1. Location
2. Severity
3. Timing
4. Modifying factors
5. Quality
6. Duration
7. Context
8. Associated signs and Symptoms
Past Medical History
1. Current medications
2. Drug allergies
3. Prior surgeries
4. Prior hospitalizations
5. Prior major illnesses or injuries
6. Immunizations
Family History
1. Health status or cause of death of near relatives
  1. Parents
  2. Siblings
  3. Childrens
2. Specific disease related to CC, HPI, ROS
3. Hereditary diseases for which the patient is at risk
Social History
1. Occupational history
2. Current employment
3. Level of education
4. Marital status or living arrangements
5. Sexual history
6. Habits
  1. Nutritional status
  2. Tobacco use
  3. Alcohol use
  4. Illicit Drug use
Review of Systems
1. Constitutional
2. Eyes
3. Ears, nose, mouth, throat
4. Cardiovascular
5. Respiratory
6. Gastrointestinal
7. Genitourinary
8. Musculoskeletal
9. Skin
10. Neurologic
11. Psychiatric
12. Hematologic or Lymphatic
13. Allergic or immunologic

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This page was written by Scott Moses, MD. This page was last revised before 5/10/08, prior to consistent tracking of revision date. This page was last published on 2/26/2010. Please send comments and questions to the editor. Contact information may be found on the page About the Family Practice Notebook. These pages are best viewed with Microsoft Internet Explorer 6.0.