| Biographic Data | Record Pt's name, age, date of birth, sex, race, ethnicity, nationality, religion, marital status, children, level of education, job, and advance directives. |
| Chief Complaint | What the Pt tells you (e.g., chest pain, nausea, abdominal pain). Use symptom analysis for chief complaint. |
| Past Medical History | Record childhood illnesses, surgical procedures, hospitalizations, serious injuries, medical problems, immunization, and recent travel or military service. |
| Medications | Prescription medications taken regularly as well as those taken only when needed (prn). Note: prn medications may not be used very often and are likely to be expired. Remind Pts to replace expired medications. Inquire about OTC drugs, vitamins, herbs, alternative regimens, and use of recreational drugs or alcohol. |
| Allergies | Include allergies to drugs, food, insects, animals, seasonal changes, chemicals, latex, adhesives, etc. Determine type of allergic reaction (e.g., itching, hives, dyspnea). |
| Family History | Health status of blood relatives, as well as that of spouse/significant other. Obtain age and cause of death of deceased family members. |
| Social History | Assess health practices and beliefs, typical day, nutritional patterns, activity/exercise patterns, recreation, pets, hobbies, sleep/rest patterns, personal habits, occupational health patterns, socioeconomic status, roles/relationship, sexuality patterns, social support, and stress coping mechanisms. |
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