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 Medications

Family Tree or Genogram Parents
 Grandparents
 Siblings
 Children

present illness section
 To evaluate health promotion

practices

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 Pap

Hematologic: 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?