The document contains questions from a social history and physical exam for a patient. It asks about the patient's living situation, habits, family medical history, current medications, and reviews symptoms for various body systems.
The document contains questions from a social history and physical exam for a patient. It asks about the patient's living situation, habits, family medical history, current medications, and reviews symptoms for various body systems.
The document contains questions from a social history and physical exam for a patient. It asks about the patient's living situation, habits, family medical history, current medications, and reviews symptoms for various body systems.
The document contains questions from a social history and physical exam for a patient. It asks about the patient's living situation, habits, family medical history, current medications, and reviews symptoms for various body systems.
Are you married or single? Do you have any children? Where do you live? Do you live alone? Do you work? Do you (smoke/ drink)? How many (packs do you smoke/ drinks do you have) a day? Have you ever tried to quit (smoking/ drinking)? Do your (hands shake/ see things) when you stop drinking? Have you ever used any drugs? Cocaine/ Heroin/Opium/ Marijuana? Do you use needles?
Shortness of breath? Exposure to TB? Chest pain? Palpitations? How many pillows do you use to sleep? How many blocks can you walk before you get tired? Anemia? Do you bruise easily? Fatigue? Dysuria? Urgency? Daily frequency? Nocturia? Hematuria? Joint pain? Weakness? Osteoporosis? Rheumatoid arthritis? Problems with concentration? Mood changes? Suicidal thoughts?
Nose bleeds? Sore throat? Bleeding gums? (Indigestion/ Heartburn/ Diarrhea/ Constipation)? What color is your stool? (Heat/ cold) intolerance? Polydipsia? Polyuria? (Hair/ nail) changes?
Chest
Does the pain move?
Is there something that (alleviates/ aggravates) the pain? Have you had this pain before? Do you suffer from any medical problems? High blood pressure? Diabetes? Heart disease? Stroke? Hepatitis? Cancer? Asthma? Emphysema? HIV? AIDS? Do any of your family members have medical problems? Have you ever been hospitalized? Are you taking any medications? Prescription? OTC? Herbal?
Weight loss? Skin (rashes/ itching/ color changes)? (Headaches/ dizziness)? Loss of consciousness? Vision changes? Do you hear as well as before? (Vertigo/ Tinnitus)?
Lie down. Sit up. Stand up. Remove your clothes (except your underwear). I am going to take your (blood pressure/ pulse). Do this. (to mimic physical action) Follow my finger. Look at the light. Raise your eyebrows. (Smile/ frown). I need to check your teeth. Im going to examine your nose. Push against my hand with your face. Raise your shoulders against my hands. Open your mouth. Stick out your tongue. Say ahh. Swallow. I am going to examine your (heart/ lungs). Breathe deeply. Breathe out. I am going to examine your abdomen. Tell me whether this hurts, when I (press/ let go). I am going to do a rectal exam. Roll over onto your (left/ right) side. Tell me as soon as you see my finger wiggling. Do you hear this? Is it louder in your right ear or your left? Walk on your (toes/ heels).
General History Hello, my name is Dr. What is your name? How old are you? Why did you come in today?
Walk like this.
Stand like this with your feet together. Close your eyes. I am going to test your balance. Touch my finger. Touch your nose. Do it again. Faster. (Push/ pull) against my hand. Squeeze. Harder. Does this feel the same as this? Does it feel sharp or dull? Say one or two according to how many points you feel. I am going to check your reflexes.
Are your periods regular? How many days between periods? How many days do they last? Are your periods heavy or light? Do you have painful periods? How many times have you been pregnant? How many children have you had? Have you had any (abortions/ miscarriages)? Have you had an ectopic pregnancy? Are you sexually active? With men, women, or both? When was the last time you had sex? Are you using birth control? Condoms? Pills? Diaphragm? IUD? Do you have any vaginal discharge? Do you have sores on your genitals? Do you have itching? Does it hurt when you have intercourse? Does it burn when you urinate? Do you have a history of UTIs? Have you had gonorrhea? Syphilis? Herpes Simplex? Chlamydia? Genital warts? Have you had uterine fibroids? Ovarian cysts? Abnormal Pap smears?
Do you have to wake up at night to
urinate? Do you have a feeling of incomplete urination? How is your urinary stream? Masters Scholars Program New York University School of Medicine, New York, NY 10016
compiled by Wayne Chung, Juliana Eng, and Janet Lai 2005 Medical Chinese Program
Do you have any penile discharge?
Have you had problems with your prostate? Cancer? BPH?
Pediatrics What was the birth weight of your child? Cesarean or vaginal birth? Were there complications? Was the baby (premature/ full-term)? Do you breast-feed, use formula, or both? How long do you feed on each breast? How many times per day? Which formula do you use? Can you show me your childs immunization record? Has your child been vaccinated against: Diphtheria, tetanus, pertussis (DTP) Hep A and B Polio? Chicken pox? Measles, mumps, rubella Pneumococcal? Meningococcal? Can your child hold his/her head up? Sit up? Crawl? Stand? Walk? Does your child (coo/ laugh/ babble/ say any words/ talk)? Do you feel safe at home? How many hours does your child sleep per night? Does your child play well with others? Does anyone smoke in the house?
What is the (date/ year/ month)? Do you know where we are right now? Remember these three words: apple, shirt, telephone. Repeat them. Can you remember the three words? From 100, keep subtracting 7. If I have $4 and lose half of it, how much will I have left? Two dollars. Take this piece of paper with your left hand. Fold it in half. Drop it.
Surgery Are you hungry. Thirsty? Are you (eating/ drinking)? Dont eat or drink anything. Is your pain controlled? Are you passing gas? Have you had a bowel movement? Are you able to get out of bed?
