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history 1. chief complaint 2. present problem/illness 3. past health history 4. family history 5. personal &social history 6. review system
Chief Complaint Pt own words
present problem/illness O, P, Q, R, S, T, Onset palliative /provoking quality of pain radiation/referral ( or location) Site/ setting/severity timing
past health history MD Shit D M Malignancy D Diabetes S Surgeries H Hospitalizations I Infections/ illness T Trauma D Drugs / allergies
family history heard Dz Diabetes Stroke Cancer
Social / personal history SOSS 1. sport/hobbies 2. occupations 3. Smoker/drinks/recrceational drugs 4. Sexual habits
Review of System from the top and working down
CAGE Questionaire 1. C cutting down 2. A Annoyed by other criticisms 3. G Guilty feeling 4. E Eye openers
Created by: xinling66