Date
Name
Email
Birthdate
Gender
Cheif Complaint - Location: where is the pain or problem?
Pain - Describe pain give rating of severity 1-5 (5 being the strongest)
Occurance - Does the pain or problem occur at a specific time?
Signs and Symptoms - Associated signs or symptoms:
Duration - How long have you had this issue? Date it started
Context - /what was going on in your life when this issue started?
Modifying Factors - What makes the problem/pain worse/better
Surgeries - Reasons for and date of surgery
Other Hospitalizations or Serious Illnesses - Reason and date
General Medical Background Vaccinations: Weight Gain: Weight loss Exercise:
Excercise Daily Weekly Other
Substances Tobacco: Alcohol: Coffee/Tea: Recreational Drugs
Family History 1 - Which of the following have affected your blood relatives? Alcoholism Arthritis Asthma Amnesia Autoimmune Disease Congenital Abnormality Depression Emphysema Diabetes Epilepsy Gonorrhea Heart Disease Gout Hay Fever / Allergies Mumps Mental Illness Paralysis Pneumonia Scarlet Fever Skin Disease Syphilis Tuberculosis Warts
Cancer - ( type )
Family History 2
Mother
Maternal Grandmother
Maternal Grandfather
Maternal Aunts/Uncles
Father
Paternal Grandmother
Paternal Grandfather
Paternal Aunts/Uncles
Sister(s)
Brother(s)
Children
