Comprehensive Health History

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Current [Comprehensive Health History
Name of interviewer:_____________________________Date of assignment: _______________

Identifying data| Y| N|
Name of interviewer| X| |
Name of patient | X| |
Date and time of interview| X| |
Location of interview| X| |
Source of data| X| |
Reliabilty of informant| X| |
Ethnicity/culture| X| |
Age and gender| X| |
Date/place of birth| X| |
| | |
Chief complaint| Y| N|
Chief complaint| X| |
| | |
Present Illness| Y| N|
Onset of symptoms| X| |
Timing| X| |
Character, quality, quantity, location| X| |
Associated events| X| |
What lessens symptoms| X| |
What increases symptoms| X| |
Treatments tried and results| X| |
Effects on other systems (appetite, energy, headache, etc)| X| | Effects on usual activities| X| |
Other| | |
| | |
Past medical history| Y| N|
Medical disorders| X| |
Surgeries| X| |
Injuries/disabilities| X| |
Other hospitalizations| X| |
Childhood illnesses| X| |
Recent health exams| X| |
Immunizations| X| |
Preventive health care| X| |
Other | | |
| | |
Medications, dosages, indications| Y| N|
Prescription meds| x| |
OTC meds| X| |
Allergies| X| |
Other | | |
| | |
Social history| Y| N|
Marital status| X| |
Family members| X| |
Housing | X| |
Work/occupation| X| |
Education| X| |
Religion| X| |
Leisure activities| X| |
Economic status| X| |
Legal| X| |
Other | | |
| | |
Family history| Y| N|
Genogram| X| |
Familial disorders| X| |
FH of alcohol/drug problems, mental illness| X| |
Other | | |
| | |
Behavioral history| Y| N|
Alcohol use (current and prior use)| X| |
Other addictive drugs (current and prior use)| X| |
Tobacco use (current and prior use)| X| |
Sexual orientation| | x|
Sexual history| X| |
Exercise| X| |
Caffeine| X| |
24 hour dietary recall| | X|
Typical dietary habits| X| |
History of weight loss or weight gain| X| |
Sleep patterns| X| |
Work patterns| X| |
Other | | |
| | |
General| Y| N|
Vital signs| X| |
Known data (height, weight, previous BP)| X| |
Usual health status| x| |
Additional data| | |
| | |
Skin and hair| Y| N|
Current problems| X| |
Previous problems| X| |
Additional data| | |
| | |
Hematologic/ immune system| Y| N|
Current problems| X| |
Previous problems| X| |
Additional data| | |
| | |
Head| Y| N|
Current problems| X| |
Previous problems| X| |
Additional data | | |
| | |
Ears| Y| N|
Current problems| X| |
Previous problems| X| |
Additional data| | |
| | |
Eyes| Y| N|
Current problems| X| |
Previous problems| X| |
Additional data| | |
| | |
Nose| Y| N|
Current problems| X| |
Previous problems| X| |
Additional data| X| |
| | |
Throat| Y| N|
Current problems| X| |
Previous problems| X| |
Additional data| | |
| | |
Neck| Y| N|
Current problems| X| |
Previous problems| X| |
Additional data| | |
| | |
Chest/lungs| Y| N|
Current problems| X| |
Previous problems| X| |
Additional data| | |
| | |
Heart/circulation| Y| N|
Current problems| X| |
Previous problems| X| |
Additional data| | |
| | |
Breasts/axillae| Y| N|
Current problems| X| |
Previous problems| X| |
Additional data| | |
| | |
Abdomen| Y| N|
Current problems| X| |
Previous problems| X| |
Additional data| | |
| | |
Urinary| Y| N|
Current problems| X| |
Previous problems| X| |
Additional data| | |
| | |
Female genitalia| Y| N|
Current problems| X| |...
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