history chart (1)

7/23/2019 History Chart (1)

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History Chart

Name_____________________________ Age____ Race____________ Sex____

PCP: ____________________________________ Last visit__________________

CC:___________________________________________________________________

______________________________________________________________________

______________________________________________________________________

HPI:Nature: Burning Aching Stabbing Shooting Throbbing Dull Other_________

Location: ______________________________________________________________

Duration: All the time AM PM _______________________________________

Onset: Insidious Gradual Acute __Years __Months __Days ago______

Character: Has it gotten worse, better? ______________________________________

Aggravating factors: Exercise Walking New Shoes ______________________

Alleviating factors:_______________________________________________________

Pain Scale:_____________________

Trauma?:______________________

Any cramping?__________________

Diabetic? Y N Glucose:_______ When? _______ HgbA1c_____ When?_______

Allergies:______________________________________________________________

Reactions:_____________________________________________________________

Medications:

____________For ______________ How often_______________ Since____________







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History Chart

PMH:Pregs: Gravida Para when?___________________________________________

Vaccinations: Tetanus DPT MMR Polio Flu HepB HIB Dont Know

Childhood ill.: Chicken Pox Measles Mumps Rubella Scarlet fever Polio Cancer

Adult ill.: DM HTN Cholesterol Asthma COPD Cancer Other:________________

STD?_______________ HIV?________________

Surgery:_______________________________ when ___________________________

Surgery:_______________________________ when ___________________________

Hospitalizations:________________________ when ___________________________

SOCIAL Hx:Occupation:____________________________________________________________

Exercise Habits:_________________________________________________________

Hobbies:_______________________________________________________________

Marital Status: Single Married Divorced Widowed

Sexual Activity/Preference: Monogamous Heterosexual Homosexual Bisexual

Children: Y N How many:______________

Smoking: Y N Pack/year___________. since_________ Quit when__________

Alcohol: Y N Type_______________ How often___________, Since________

Recreational Drugs: Y N Type_________________________

FAMILY Hx:Mother: Living Deceased @ age_____ DM HTN Cancer, ___________________

Father: Living Deceased @ age_____ DM HTN Cancer,____________________

Brother: #___ Living Deceased @ age ___ DM HTN Cancer, __________________

Sister: #___ Living Deceased @ age ___ DM HTN Cancer,_____________________

History of family problems: Y N __________________________________________


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History Chart

ROS:General Health: Poor Fair Good Excellent Grade?____/10

Any changes in?:Weight: Increased Decreased How much___________ Since________

Appetite: Increased Decreased How much___________ Since________

Endocrine Sensitivity to hot/cold Polydipsia Alopecia Lethargy

Skin Rashes Psoriasis Eczema Pruritus Bruising/Bleeding Urticaria

Head Headaches Dizziness Fever

Eyes Vision Loss Cataracts Diplopia Dry eyes Glaucoma

Ears Tinnitus Deafness Infections

Nose Rhinitis Sinusitis Nose Bleeds

Mouth Sore throats Dysphagia Sores Swollen tongue Bleeding gums

Neck Pain Stiffness Lumps Edema

Resp Dyspnea Asthma/Wheezing Bronchitis Congestion EmphysemaPneumonia

CV HTN Heart Murmur MI Claudication Phlebitis Peripheral Edema

GU Polyuria Dysuria Nocturia Hematuria Incontinence

GI Ulcer Thirst Diarrhea Constipation Melena JaundiceHepatitis Vomiting Abdominal Pain

Gyn Last menstrual cycle________________________________________Problems?________________________________________________Replacement Therapy?______________________________________

Skel/Musc Arthritis (RA, OA, Gout) Osteoporosis Back Pain Digits&Nails

Neuro Depression Mood Swings Illusions Hallucinations Eating disorderDrug habituation Sleeping disorder Nervousness Insomnia

Is there anything else you wish to tell me about your health?

Do you have any questions for me?


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History Chart

Lower Extremity PE:

Vascular:

Skin temp. (proximal to distal)______________________________________________

DP Pulse:______ PT Pulse:______ Popliteal:_____ Femoral:_____ CFT:_______

Edema? Y N Location_____________ Character____________ Scale_________

Varicosities? Y N Location___________________

Neuro:

Protective Sensation:_____________________________________________________

Vibratory Sensation:_____________________________________________________

Proprioceptive Sensation:_________________________________________________

Light Touch___ Patellar Reflex___ Achilles Reflex___ Babinski?___ Clonus?___

Derm:

Toenails: intact?______ dystrophic?______ incurvated?______

Webspaces: dry/clean/intact?_____________ debris?_______ maceration?______

Hyperkeratotic tissue?___________________ Skin texture?_____________________

Itching?______________ Lesions?________________ Erythema?______________

Ulcer:

where?________________________________________________________________

length, width, depth, base, rim, peri-wound:___________________________________

Musculoskeletal:

Muscle Strength: PF_________, DF________, Inv.________, Ev._________

ROM: AJ___________, STJ__________, 1stMPJ___________ pain/crepitus?______

Structural deformities noted?_______________________________________________

Pain on palpation?_______________________________________________________

DDX:

history chart (1)

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