Patient Profile

Name
Age
Date of Birth

Presenting complaint
What patient tells you is wrong

History of Present Complaint (The gossip)

What is it we may do today?
Socrates
o Site
Where is the pain? Or the maximal site of the pain.
o Onset
When did the pain start, and was it sudden or gradual?
Include also whether if it is progressive or regressive.
o Character
What is the pain like? An ache? Stabbing?
o Radiation
Does the pain radiate anywhere? (See also Radiation.)
o Associations
Any other signs or symptoms associated with the pain?
o Time course
Does the pain follow any pattern?
o Exacerbating/Relieving factors
Does anything change the pain?
o Severity
How bad is the pain? (1-10)

Past Medical History

JADE (General) / TAB (Respiratory) / MARCH (Cardiovascular)
o General
Jaundice
Anemia
DM
Epilepsy
o Respiratory
TB
Asthma
Bronchitis
o Cardiovascular
MI
Angina
 Rheumatic fever
Cholesterol
Hypertension
Have you had these symptoms before?
Operations
Drug History
o Name
o Dose
o Frequency (OD, BD)
o Root of delivery
Allergies
o What happens when you get the allergy
Family History
o Any conditions that run in the family that I should know about?
Social History
o Smoke
Amount
o Alcohol
Amount (units/ week)
o Occupation
o Recreational Drug Use
o Activity of daily livings (ADL)
Can they:
Wash
Feed
Transfer one place to another (sit/lying)
Mobility
Systemic Inquiry
o CVS
Any chest pain recently
Palpitation
Shortness of breath
Syncope (fainting)
Chest pain
o Respiratory System
Shortness of breath
Wheezing (high-pitched whistling sound made while breathing)
Stridor
High-pitched breath sound
Hemoptysis (coughing of blood)
Coughing
Sputum when coughing
o GI
 Vomiting
Diarrhea
Loss of weight
Loss of Appetite
Hematemesis (Vomiting blood)
Slime or mucus when pooping
Change in bowl habits
Bloating
Strain to pass feces (Rectal tenesmus)
o Genital/ Urinary System
Blood in urine
Pain when urinating
Nocturia
Frequency
Urgency
Dribbling
Hesitance
Incomplete voiding
o Musculoskeletal System
Morning stiffness or night
Pain: More in the evening or at night
o CNS
Faints
Weakness
Headache
Confusion
Slurred in speech
o Skin
Rashes
Ulcer
Lumps or bumps
o Hematologic
Anemia, easy bruising or bleeding, past transfusions and/or transfusion
reactions.
o Endocrine
Thyroid trouble
Heat or cold intolerance
Excessive sweating,
excessive thirst or hunger
Polyuria
Change in glove or shoe size.
o Psychiatric
Nervousness
Tension
 Mood, including depression
Memory
o change, suicide attempts, if relevant.
ICE (Ideas, Concerns, Expectation)
o Ideas