Exam Template

Contents (below)

Adult Exam: Comprehensive History

I. Goals

describe person and milieu
understand ongoing disease processes
understand prior probabilities (adjusted risk)

II. Introduction

A. age, weight (child), ethnicity, social

III. HPI

chief complaint, symptoms: nature (quality, quantity), location and course (time and space), factors (mitigating, provoking), associated symptoms, relation to sleep, prior diagnoses and treatments
relevant components from other sections
risk factors, functional capacity
patient's interpretation, concerns

IV. Allergies and Sensitivities

medications
latex, anaphylactic environmental

V. Medications

prescription
birth control
OTC, vitamins
"alternative", health food, dietary supplements

VI. Environment/Exposures

A. substance use: smoking, alcohol
B. occupational history: toxins, fumes, dusts
C. social: sexual exposures, travel, violence
D. home/auto: detectors, helmets, seatbelts
E. exercise/activity level, diet (fats, foods avoided)
F. infectious: immunizations, tuberculosis, hepatitis, STD
G. general: sun

VII. Genetic

family history: CA (breast, GI, skin), DM, IHD, depression, suicide, psychosis, glaucoma, hypertension

VIII. Medical History

A. health maintenance
B. current/recent providers and care resources.
C. obstetrical
D. psychiatric
E. trauma
F. surgical
G. medical

IX. Psychosocial

job, family, schooling, hobby, sexual
relationships, violence, abuse

X. ROS

general: fever, weight changes, sleep changes, energy level
endocrine: thyroid, diabetes
hematologic
neurological/psychiatric: dizziness/vertigo, sensory changes, memory, mood, anxiety
skin: nails, pigmented lesions, hair loss
heent: hearing, vision, rhinitis, dental, thyroid, swallowing
breast: self-exam
respiratory
cardiovascular: apnea, snoring, sleep disturbance, claudication
GI: gas, hematochezia, melena, hemorrhoids, constipation
GU: incontinence, hesitancy, frequency
Gyne: menstrual history, last PAP, contraception
MS

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