Scribd
Upload
2 views10 pages

History-Template

The document is a comprehensive medical history template that collects various patient information, including general data, chief complaints, review of systems, gestational and birth history, nutritional history, developmental history, past medical history, gynecologic history, family history, socioeconomic history, and environmental history. It is designed to gather detailed information about the patient's health status and background for medical assessment. Each section includes specific inquiries to ensure thorough documentation of the patient's medical and social context.

Uploaded by

JanelaAngeliGonzalesPanopio
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
2 views10 pages

History-Template

The document is a comprehensive medical history template that collects various patient information, including general data, chief complaints, review of systems, gestational and birth history, nutritional history, developmental history, past medical history, gynecologic history, family history, socioeconomic history, and environmental history. It is designed to gather detailed information about the patient's health status and background for medical assessment. Each section includes specific inquiries to ensure thorough documentation of the patient's medical and social context.

Uploaded by

JanelaAngeliGonzalesPanopio
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
You are on page 1/ 10

General Data

Name
Birthdate
Age
Sex
Nationality
Birthplace
Religion
Address
Informant
Relation to patient
Reliability

Chief
Complaint
HPI
Review of Systems
General ( ) Weight loss/gain ( ) Activity level ( ) Appetite ( ) Delay in Growth
Skin ( ) Rash ( ) Pigmentation ( ) Hair Loss ( )Acne ( )Pruritus
HEENT ( ) Headache ( ) Dizziness ( ) Visual Difficulty ( ) Lacrimation ( ) Hearing ( ) Aural Discharge ( )
Nasal Discharge ( ) Epistaxis ( ) Toothache ( ) Salivation ( ) Sore Throat
CV ( ) Orthopnea ( ) Cyanosis ( ) Easy Fatigability ( ) Fainting spells
Resp ( ) Chest pain ( ) Cough ( ) Difficulty of breathing ( ) Cyanosis
GIT ( ) Nausea/Vomiting ( ) Diarrhea ( ) Constipation ( ) Encopresis ( ) Passage of Worms, ( )
Abdominal Pain ( ) Jaundice ( ) Food Intolerance ( ) Pica
GUT ( ) Color of urine ( ) Burning sensation ( ) Frequency ( ) Adequacy of stream ( )
Discharge
( ) Enruresis ( ) Edema of the hands and feet ( ) Itching ( ) Dysmenorrhea ( ) Menometorrhagia
Endo ( ) Breast Assymetry ( )Pain/Discharge ( ) Breast mass ( ) Paltpitations ( ) Cold/heat intolerance
( ) Polyuria ( ) Polydipsia ( ) Polyphagia
Hemo ( ) Pallor ( ) Bleeding ( ) Easy Bruisability
Msk ( ) Joint/Muscle Pain ( )Stiffness ( ) Erythema of joints ( ) Limitation of ROM ( ) Limping
Nervous / ( ) Tremors ( ) Sleep problems ( ) Convulsions ( ) Weakness or Paralysis ( ) Mental deterioration
Behavioral ( ) Personality or behavioral changes ( ) Memory loss ( ) Eating problems ( ) School failures
( ) Temper outburst ( ) Hallucinations
Gestational History
Age of mother during pregnancy
Parity
Health
Nutrition
Infection
Intake of drugs/medicaiton
Roentgen exposure
Antenatal utz
Duration of gestation

Birth History
Mode of delivery
Person who attended
APGAR
Maturity
Anthropometric
Need for resuscitation
Congenital birth injury
Neonatal History
Routine newborn Care?
Jaundice? Onset?
Convulsions
Hemorrhage? Where?
Resp / Feeding difficulties
Newborn / Hearing Screening

Nutritional Hx
< 2 years old
Breastfeeding:
Exclusive / Mixed
Frequency
Duration for each
breast
Complementary food:
Age started
Type
Consistency
Amount
Frequency
Usual intake
Breakfast
Lunch Dinner
AM Snack
PM Snack
Feeding Difficulties
Caloric Intake
> 2 years old
Appetite
Usual intake
Breakfast
Lunch Dinner
AM Snack
PM Snack
Food likes/dislikes
Multivitamins / Fe
Supp
Food Sources
Caloric Intake
Developmental History < 6 years old
Gross Motor
Fine Motor
Receptive/Expressive
Language
Psychosocial
Cognitive

Dental Eruptions:
Behavioral Problems
Urinary continence: Day / Night
Toilet training: Started / Ended
Temper tantrums
Head Banging
Phobias
Pica
Night Terrors
Sleep Disturbance

School?
Living with? Own
Home & room? Gets
along? Rules?

family
School? Subject?
Education & Grades?
Suspension?
Bully?
Employment
Sports? Hobbies?
Activities
Drugs, Alcohol
& Tobacco
Sexuality
Sleep? Eat? Self-
Suicide / image?
Sad/bored/iso?
Confidant? Self-
Depression harm?
Frat/Gang?
Safety Seatbelt?
Pedestrian?
Religion?
Spirituality Participation?
Past Medical History
Illnesses
Hospitalizations
Allergies
Injuries
Surgery
Blood Transfusion

Gynecologic History
M
I
D
A
S

Family History
Hereditary Neuro
Congenital Hema/Onco
Resp/Allergy Chronic: TB HIV
CV Autoimmune
Endo/Metab GU
Socioeconomic History
Family Profile
Primary caregivers
Breadwinner
Occupation of Parents

Environmental History
Housing
Ventilation
Pets
Exposure to cigarette smoke
Pollutants
Factories/Poultry/Piggery
Garbage Disposal
Water Source

You might also like