HISTORY

TAKING FORMAT


1. Chief Complaint
2. History of Presenting Illness (HPI)
Onset
Location
Duration
Character
Aggravating/Alleviating factors
Associated symptoms
Radiation
Severity

Frequency
Progression

3. Past Medical History (When , What, Medications, Compliance,
Controlled?)
4. Past Surgical History (When, Why)
5. Allergies (Medications, Food, Seasonal)
6. Medication History (Routine meds, herbal, OTC drugs)
7. Previous Hospitalizations /Any Trauma
8. Family History (Any ill contacts recently, diseases running in family)
9. OBGYN (LMP, Menarche, Cycles/Regularity/Flow/pads per day, PAP
smear, pregnancy, abortions, cramping, spotting, PV discharge)
10. Sexual (Active? Orientation? Condom use? Multiple partners? STDs? HIV
status? Libido?, Any other issues?)
11. Social
Smoking (Duration, Packs per day, interested to quit)
Alcohol (Duration, Packs per day, interested to quit)
Drugs (What drug? Route? Duration? Last dose? interested to quit)
Any specific diet (DM/HTN/High Cholesterol)
Recent Travel
Occupation
Exercise/Sleep
Stress (Loss of interest? Poor concentration? Guilt? Self harm? Suicide?)

12. ROS
Constitutional: Fatigue, Loss of weight/ Appetite, Fever
HEENT: Headaches, Visual Problems, Ear pain or discharge, Dizziness,
Tinnitus, Nasal Congestion, Throat pain
CVS: Palpitations, Chest pain, sweating, Syncopy
RS: SOB, Cough, expectoration, Hemoptysis
MSK: Changes in skin/hair, rash, joint pains/stiffness, photosensitivity
GI: Dysphagia, heartburn, Diarrhea, Constipation, Hematochezia, N/V
GU: Dysuria, Hematuria, Polyuria
CNS: Weakness, tingling/numbness, seizures