A. Identification and Vital Statistics

1. Name, (residence), age; birth date, place of birth where relevant
2. Nationality, race, marital status, occupation where relevant
3. Informant- relationship to patient, name

B. Chief Complaint

1. Usually single problem/condition that motivated patient to seek care-duration
2. In general, more than one chief complaint is not appropriate

C. Present Illness

1. Symptoms and pertinent negatives
2. Onset and duration; associations with specific events
3. Character and quality of condition
4. Current level of activity and degree of disability

D. Past Medical History

1. General Health- lifetime summary, list of relevant risk factors
2. Infectious Diseases- dates, complications, therapies
3. Operations, Injuries- names, dates, operative diagnoses
4. Previous hospitalizations- dates and names of hospitals
5. Transfusion History

E. Medications

1. Names
2. Doses
3. Allergies to medications is very important part of history

F. Review of Systems

1. Integument
   1. Skin: color, pigmentation, temperature, moisture, lesions, pruritus, scaling, bleeding
   2. Hair: hair color, texture and distribution
   3. Nail: color, changes, brittleness, ridging, pitting, clubbing
2. Lymph Nodes - enlargement, pain, suppuration, draining sinuses, location
3. Connective Tissue
   1. Bones: fractures, dislocations, sprains,
   2. Joints: arthritis, pain, swelling, stiffness, migratory distribution, degree of disability
   3. Muscles: weakness, wasting, atrophy, pain, night cramps
4. Hematopoietic System
   1. Anemia (type, therapy, response)
   2. Bleeding (spontaneous, traumatic, familial, transfusions
   3. Lymphadenopathy, Infections
5. Endocrine
   1. General: history of growth, body configuration and weight, head, and feet
   2. Hair distribution, skin pigmentation, dryness of skin and hair
   3. Thyroid: goiter, exophthalmos, heat or cold intolerance, tremor
   4. Diabetes: polyphagia, polydipsia, polyuria, glycosuria
   5. Secondary sex characteristics, impotence, sterility, treatment
6. Allergic/Immunologic System
   1. Vaccinations and immunizations
   2. Vasomotor rhinitis, asthma, hay fever
   3. Dermatitis, urticaria, angioneurotic edema, conjunctivitis, eczema
   4. Seasonal incidence of the foregoing, known sensitivity to pollen, food, drugs
   5. Previous skin tests and results, desensitization, serum injections
   6. TB test results
7. Head- headaches, migraines, trauma, vertigo, syncope, convulsive seizures
8. Ears- deafness, tinnitus, vertigo, discharge, pain, mastoiditis, operations
9. Eyes- visual loss, color blindness, diplopia, hemianopsia, trauma, inflammation, glasses
10. Nose- coryza, rhinitis, sinusitis, discharge, obstruction, epistaxis, frequency of colds
11. Mouth- soreness, symptoms referable to teeth
12. Throat- hoarseness, sore throats, tonsillitis, voice changes
13. Neck- swelling, lymph node character, goiter, stiffness, range of motion
14. Breasts
    1. Development, lactation, gynecomastia
    2. Trauma, lumps, pain, nipple discharge and/or changes
15. Respiratory System
    1. Dyspnea: nocturnal, rest, exertional, orthopnea, pain, cyanosis
    2. Wheezing, cough, sputum, night sweats, pleurisy, bronchitis, smoking
    3. Pneumonia, hemoptysis, other respiratory infections, tuberculosis (exposure)
16. Cardiovascular System
    1. Chest pain, shortness of breath, exertional, rest, smoking, hypertension
    2. Palpitation, tachycardia, irregular rhythms, cyanosis
    3. Exercise tolerance, edema, ascites, claudication
    4. Cardiac Drugs, rheumatic fever, syphilis, diphtheria
    5. Cold extremities, phlebitis, postural or permanent skin color changes
    6. Cocaine abuse, other recreational drug abuse
17. Gastrointestinal System
    1. Appetite, changes in weight, dysphagia, flatulence, abdominal pain or colic
    2. Nausea, vomiting, diarrhea, constipation, frequency, consistency
    3. Hematemesis, jaundice (pain, fever, duration, color of urine)
    4. Stools - color, frequency, consistency, odor, gas, cathartics), hemorrhoids
    5. Change in bowel habits.
18. Genitourinary System
    1. Urine: color, polyuria, oliguria, nocturia, dysuria, hematuria, pyuria, urinary retention, frequency, incontinence, pain, passage of stones or gravel.
    2. Menstrual history - age at onset, frequency, regularity, duration, amount of flow, leukorrhea, dysmenorrhea, date of last period, date and character of menopause, postmenopausal bleeding.
    3. Pregnancy history -number, abortions, miscarriages, stillbirths, chronologic sequence, complications.
    4. Venereal history - chancre, bubos, papillomas, penile discharge, treatment
19. Nervous System
    1. Cranial Nerves - disturbance of smell or vision, orofacial paresthesias and chewing difficulty, facial weakness, disturbed hearing and/or equilibrium, difficulty with speech, swallowing and/or taste, limited neck motion.
    2. Motor system - paralyses, atrophy, involuntary movements / seizures, gait, coordination
    3. Sensory system - pain, lightning pain, girdle pain, paresthesia, hypesthesia, anesthesia
    4. Autonomic system - control of urination and defecation, sweating, erythema, cyanosis, pallor, reaction to heat and cold.
20. Psychiatric History
    1. Reactions to and influences of parents, siblings, spouse, children, friends and associates
    2. Sexual adjustments, successes and failures, illnesses, lability of mood, hallucinations
    3. Grandiose ideas, nervous breakdowns, sleep disturbances
21. PRIME-MD Tool for Screening Common Mental Disorders [1]
    1. Primary Care Evaluation of Mental Disorders
    2. Completed by patients in primary care setting
    3. For screening depressive, anxiety, alcohol, somatoform, and eating disorders
    4. Self administered version is very effective, sensitive, and does not require clinician
    5. Based on results of PRIME-MD, clinician can focus discussion

References

1. Spitzer RL, Kroenke K, Williams JBW. 1999. JAMA. 282(18):1737