PATIENT HISTORY TAKING OUTLINE

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Case History     (#1 = chief complaint; #2 = secondary complaint)

Patient Name:________________________________ Date:_______

• ONSET: of chief complaint + location - insidious?, traumatic?
• PROVOCATION: what makes it worse?
• PALLIATIVE: what makes it better? Self treatment?
• PERSISTENCE: how long do these complaints last?
• PROGRESSION: are the complaints gotten better/worse?
• PRIOR: have you had similar complaints before?
• QUALITY: of pain
• RADIATION: does the pain "move" or radiate?
• RESTRICTIONS: does the pain stop you from doing any of your normal activities?
• SEVERITY: scale 1-10, 10 being the most severe.
• SEQUELA: have you had any conditions in the past that have left you with ongoing problems?
• TIMING: better or worse in the morning or at night?
• AUTO ACCIDENTS: Dates, Car Towed? Totaled? Paramedics? Direction of impact- hit your head?
• OTHER MAJOR TRAUMAS: Concussions?
                                              Dislocations?
                                              Fractures?
                                              Falls?
• MEDICATIONS: for what purpose:
• ALLERGIES: to what - what reaction?
• SURGERIES: any complications?
• HOSPITALIZATIONS: What for?
                                      How long?
                                      When?
  **personal and family history**
• BLOOD SUGAR/ DIABETES: yourself or family member?
• CANCER: yourself or family member?
• STROKE: yourself or family member?
• DOCTORS: Being seen?
            What for?
            Heart?
            Chest pain?
            Blood Pressure?
• X-RAYS: when and of what part of your body? Were you Standing for the X-Ray?
• SOCIAL HISTORY: tobacco use, alcohol, drugs, sexual history, stress level, Head Aches?
                     DIET: coffee, tea, chocolate, sodas, 5 servings of fruits & vegetables
  

  
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