Identifying Data:
Age
Gender
Occupation
Marital status
Source of history: usually the patient, but can be a family member or friend, if appropriate establish source of referral, because a written report may be needed
Chief:
The one or more symptoms or concerns causing the patient to seek care
Amplifies the chief complaint
Describes how each symptom developed
Includes patient’s thoughts and feelings about the illness
Putll in relevant portions of the review of systems, called “pertinent positives and negatives”
May include medications
Allergies
Habits of smoking and alcohol
which are frequently pertinent to the present illness
Past history:
Lists childhood illlnesses
List adult ilnesses with dates for at least four categories:
Medical
Surgical
Obstetric / gynecologic
Psychiatric
Includes immunizations
Screening tests
Lifestyle issues
Home safety
Family history:
Outlines or diagrams age and health
Or age and cause of death
of siilings, parents and grandparents
Documents presence or absence of specific illnesses in family
Personal and social history:
Describes education level
Family origin
Current household
Personal interests
Lifestyle
Review of systems:
Documents presence or absence of common symptoms related to each major body system
Use inspection, palpation, auscultation and percussion
Bates, Barbara. (1928). Guide to physical examination and history-taking. United States: Wolters Kluwer.