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    Saint Louis University School of Medicine Department of Medicine General Data: Past Medical History

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    MarieCris
    This document contains a template for collecting a patient's medical history. It includes sections for identifying information, chief complaint, history of present illness, past medical history, family history, social history, review of systems, and notes. The goal is to gather relevant information on the patient's health status and any factors that could impact their care.

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    Saint Louis University School of Medicine Department of Medicine General Data: Past Medical History

    Uploaded by

    MarieCris
    41 views3 pages
    This document contains a template for collecting a patient's medical history. It includes sections for identifying information, chief complaint, history of present illness, past medical history, family history, social history, review of systems, and notes. The goal is to gather relevant information on the patient's health status and any factors that could impact their care.

    Original Description:

    Hx

    Original Title

    History Checklist

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    This document contains a template for collecting a patient's medical history. It includes sections for identifying information, chief complaint, history of present illness, past medical history, family history, social history, review of systems, and notes. The goal is to gather relevant information on the patient's health status and any factors that could impact their care.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    41 views3 pages

    Saint Louis University School of Medicine Department of Medicine General Data: Past Medical History

    Uploaded by

    MarieCris
    This document contains a template for collecting a patient's medical history. It includes sections for identifying information, chief complaint, history of present illness, past medical history, family history, social history, review of systems, and notes. The goal is to gather relevant information on the patient's health status and any factors that could impact their care.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    of 3

    SAINT LOUIS UNIVERSITY

    SCHOOL OF MEDICINE
    PAST MEDICAL HISTORY:
    DEPARTMENT OF MEDICINE
    Childhood Illnesses (if relevant): _______________________________________
    GENERAL DATA:
    Adult diseases: ____________________________________________________________
    Name:___________________________________________________________________
    Treatment: ________________________________________________________________
    Address: _______________________________________________________________
    Previous confinements: __________________________________________________
    Age: __________ Sex: ______ Birthdate: ________________Race: ___________
    Surgeries/year: ___________________________________________________________
    Religion: __________ Marital Status: ________Occupation: _____________
    Adult Vaccinations: _______________________________________________________
    Informant: _________________________________Reliability: ____________%
    Lab test/results: __________________________________________________________
    Allergies: __________________________________________________________________
    CHIEF COMPLAINT:

    OB-GYNE HISTORY:
    HISTORY OF PRESENT ILLNESS: (for all female patients):
    Onset: _____________________________________________________________________ LMP: _______________________________________________________________________
    Precipitating factors: _____________________________________________________ OB score: Gravida_____Parity_____
    Quality: ____________________________________________________________________ Term_____Preterm_____Abortion_____ Living _____
    Radiation: _________________________________________________________________ (if relevant):
    Relieving factors: _________________________________________________________ Duration of menses: _____________No. of pads per day: _________________
    Drug. Dosage, effect (if any): ____________________________________________ Dysmenorrhea: __________ Family Planning method: ___________________
    Severity/Setting: _________________________________________________________ Papsmear: __________ Last sexual contact: _______________________________
    Timing/Duration/Frequency: ___________________________________________ No. of sexual partner/s: __________ Age of menopause: _________________
    Location: __________________________________________________________________
    Associatedmanifestations/symptoms:_________________________________________ FAMILY HISTORY:
    ____________________________________________________________________________________ Heredofamilial diseases: _________________________________________________
    _______________________________________________________________
    Immediate family member with heredofamilial diseases: eye/ear/nose discharge ( ) hearing loss ( ) colds ( ) epistaxis ( ) gum
    ____________________________________________________________________________________ bleeding ( ) sore throat ( ) hoarseness ( ) goiter ( ) neck stiffness ( )
    ______________________________________________________________________ swollen glands
    Deceased immediate family members: Breasts: ( ) lumps ( ) pain ( ) nipple discharge
    _____________________________________________________________________________ Respiratory: ( ) cough ( ) sputum (color, quantity) ( ) hemoptysis ( )
    Age and Cause of death: _________________________________________________ dypsnea ( ) wheezing ( ) pleurisy
    Cardiovascular: ( ) chest pain ( ) palpitations ( ) dyspnea ( ) orthopnea (
    PERSONAL AND SOCIAL HISTORY: ) paroxysmal nocturnal dyspnea ( ) edema
    Smoking (Y/N): _______ Sticks/day: _______ Years of smoking: _________ Gastrointestinal: ( ) dysphagia ( ) heartburn ( ) anorexia ( ) vomiting ( )
    Quit smoking at age or year: ______________Drinking(Y/N):_____________ constipation ( ) diarrhea ( )abdominal pain ( ) melena ( ) hematochezia (
    Type of alcoholic beverage/Amount/Frequency per week: ) jaundice
    _____________________________________________________________________________ Peripheral Vascular: ( ) intermittent claudication ( ) leg cramps ( )
    Source of drinking water: _______________________________________________ edema ( ) varicose veins
    Garbage disposal: ________________________________________________________ Genitourinary: ( ) dysuria ( ) hematuria ( ) nocturia ( ) oliguria ( )
    Type of toilet: ____________________________________________________________ frequency ( ) hesitancy ( ) dribbling ( ) discharge ( ) dyspareunia
    History of travel: _________________________________________________________ ( ) vaginal pruritus ( ) vaginal bleeding
    Exposure to endemic diseases: _________________________________________ Musculoskeletal: ( ) muscle or joint pain ( ) stiffness, ( )weakness ( )
    Dietary preference: ______________________________________________________ limitation of motion ( ) trauma
    Active or sedentary ______________________________________________________ Neurologic: ( ) change in speech ( ) change in orientation ( ) weakness ( )
    numbness or loss of sensation ( ) tingling or pins and needles, ( )
    REVIEW OF SYSTEMS: (Choose 5 symptoms per system) seizures
    General: ( ) weight change ( ) fever ( ) weakness ( ) pain Psychiatric (if relevant): ( ) nervousness ( ) tension ( ) depression ( )
    Skin: ( ) rashes ( ) lumps ( ) sores ( ) itching ( ) dryness memory change ( ) suicide attempts
    HEENT: ( ) headache ( ) trauma ( ) dizziness ( ) blurred vision ( ) glasses
    or contact lenses ( ) eye redness ( ) diplopia ( ) cataracts ( ) tinnitus ( )

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