Past mental health problemshematologic anemia
O - Objective Data: Examination of body systems and expected findings.
What the healthcare provider sees!
Judge how reliable the informant
seems and how willing he or she is to communicate. Note any special circumstances such as use of an interpreter.
Childhood Illnesses
Accidents or Injuries
Serious or Chronic Illness Hospitalizations
Operations
Obstetric History
Immunizations
Last Examination Date Allergies
Current MedicationsFamily Tree or Genogram Parents
Grandparents
Siblings
Childrenpresent illness section
To evaluate health promotionpractices
Eyes: difficulty with vision (blurred, double, spots/specks flashing lights),watering, dryness, discharge,pain,redness, use of glasses, contacts, last eye exam, glaucoma screen
Ears: any problems with hearing or use of hearing aids, pain, vertigo, tinnitus, discharge, history of infections
Axilla: any lumps, tenderness, rash
Respiratory system: cough, sputum, wheezing, shortness of breath, pain with breathing, history of lung disorder (emphysema, asthma, toxin exposure)
Male genital: penis or testicular pain, sores or lesions, penile discharge, lumps, hernias.
Female genital: menstrual history (LMP, age at menarche, cycle length/duration/regularity, amount of bleeding), bleeding between periods, bleeding after sex, dysmenorrhea,vaginal itching burning, discharge, age at menopause,
symptoms of menopause, last PapHematologic: anemia, easy bruising or bleeding, transfusion history
Endocrine: history of diabetes or diabetic symptoms (polyuria, polydipsia, polyphagia), history of thyroid disease or symptoms of the same (heat/cold intolerance change in skin texture, excessive sweating, relationship between appetite and weight, changes in hair texture, distribution, nervousness, tremors, fatigue)
What are your health goals? What do you expect from your
healthcare provider?
Any weight loss or gain, how much and over what time interval?
Any recent illness…etc?