Date__________________________
Examiner _____________________
.
BIOGRAPHICAL DATA
Name ________________________________ Phone
____________________________________
Address
________________________________________________________________
_________
Birth date ___________________________
_______Birthplace ____________________________
Age ________ Gender ________ Marital Status_________ Occupation
_____________________
Race/Ethnic Origin ____________________ Employer
___________________________________
II
.
SOURCE AND RELIABILITY
III
.
REASON FOR SEEKING CARE
(CC)
:
Main reason for consulting health professional. State
briefly in client’s own words (when possible). State onset and duration briefly.
IV
.
PRESENT HEALTH
OF HISTORY
OF PRESENT ILLNESS
:
Needs to be well organized and seque
ntially developed. Clear, chronological account of problem
for which client is seeking care. Should include:
O
.
O
nset
:
Exactly when did it start? When did you first notice it?
P
.
Provocative or Pa
lliative
:
What brings it on? What where you doing when y
ou first
noticed it? What makes it better? Worse?
Q
.
Quality or Quantity
:
How does it look, feel, or sound? How intense/severe is it?
R
.
Region or Radiation
:
Where is it? Does it spread anywhere?
S
.
Severity Scale
:
How bad is it (on a scale of 1 to 10)? Is
it getting better, worse, staying the
same?
T
.
Timing
:
Is it constant or does it come or go?
Duration
How long did it last?
Frequency
How often does it occur?
U
.
Understanding patients perception of th
e problem
What do you think it means?
ADD. Associated Factors,
Significant negatives
: Is this primary symptom associated with any