History Chart

Name_____________________________

Age____ Race____________

PCP: ____________________________________

Sex____

Last visit__________________

CC:___________________________________________________________________
______________________________________________________________________
______________________________________________________________________

HPI:
Nature: Burning

Aching

Stabbing

Shooting

Throbbing Dull

Other_________

Location: ______________________________________________________________
Duration:

All the time

Onset: Insidious

AM

Gradual

PM _______________________________________
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____________
____________For ______________ How often_______________ Since____________
____________For ______________ How often_______________ Since____________
____________For ______________ How often_______________ Since____________
____________For ______________ How often_______________ Since____________
____________For ______________ How often_______________ Since____________

History Chart

PMH:
Pregs: Gravida

Para

when?___________________________________________

Vaccinations: Tetanus

DPT

MMR Polio Flu HepB

Childhood ill.: Chicken Pox Measles Mumps Rubella

HIB

Dont Know

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

Sexual Activity/Preference: Monogamous

Children: Y

Widowed

Heterosexual

Homosexual

Bisexual

How many:______________

Smoking: Y N

Pack/year___________. since_________

Alcohol: Y

Type_______________ How often___________, Since________

Recreational Drugs: Y

Quit when__________

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 __________________________________________

History Chart

ROS:
General Health:

Poor

Fair

Any changes in?:

Weight:
Increased
Appetite: Increased

Good

Excellent

Decreased
Decreased

Grade?____/10

How much___________ Since________

How much___________ Since________

Endocrine

Sensitivity to hot/cold

Polydipsia

Skin

Rashes Psoriasis Eczema Pruritus Bruising/Bleeding Urticaria

Head

Headaches

Dizziness

Fever

Eyes

Vision Loss

Cataracts

Diplopia

Ears

Tinnitus

Deafness

Nose

Rhinitis

Sinusitis

Mouth

Sore throats

Neck

Pain

Resp

Dyspnea Asthma/Wheezing
Pneumonia

CV

HTN

GU

Polyuria

GI

Ulcer Thirst Diarrhea Constipation

Hepatitis 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 disorder

Drug habituation Sleeping disorder Nervousness Insomnia

Dry eyes Glaucoma

Nose Bleeds
Sores

Lumps

Heart Murmur
Dysuria

Lethargy

Infections

Dysphagia

Stiffness

Alopecia

MI

Swollen tongue

Edema
Bronchitis

Claudication

Nocturia

Hematuria

Congestion

Emphysema

Phlebitis Peripheral Edema

Incontinence
Melena

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

Do you have any questions for me?

Bleeding gums

Jaundice

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__________, 1st MPJ___________ pain/crepitus?______

Structural deformities noted?_______________________________________________
Pain on palpation?_______________________________________________________

DDX: