IDENTIFYING DATA

• NAME (AND NICKNAME) AND AGE

• DATE AND PLACE OF BIRTH
• PARENTS NAME
• INFORMANT
• RELIABILITY
• RELATIONSHIP
• ADDRESS AND PHONE NUMBER
• REFERRAL SOURCE AND EXPECTATION OF
REFERRING MD
 CHIEF COMPLAINT
• DEFINITION: ONE OR MORE SYMPTOMS OR OTHER
CONCERNS FOR WHICH THE PT (OR PARENTS) ARE
SEEKING CARE OR ADVISE
• INCLUDES 3 IMPORTANT THINGS:
• NATURE OF THE COMPLAINT
• LOCATION OF THE COMPLAINT
• TIME OF ONSET (I.E. DURATION)
 CHIEF COMPLAINT
• CHIEF COMPLAINT CAN BE WRITTEN AS:
• SYMPTOM
• LESS OR MORE THAN USUAL
• HEALTH EVALUATION REQUEST