History of presenting illness

General

HEENT

Dental

Cardiovascular

Respiratory

GI tract

Genitourinary

Endocrine

Obs & Gyn

Musculoskeletal

Neuro

Psychiatry

Pediatrics

Others

Sleep:

Restless sleep

Daytime sleepiness

Decreased sleep

Unrefreshing sleep

Choking during sleep

Sleep fragmentation

Parasomnia

Nightmares

Night terrors

Appetite:

Increased appetite

Decreased appetite

Loss of appetite

Activity:

Decreased activity

Decreased energy

Feeling tired

Exercise intolerance

Weight:

Weight gain

Weight loss

Cachexia

Height:

Short stature

Tall stature

Pain:

Arm pain

Forearm pain

Hand pain

Thigh pain

Leg pain

Foot pain

Deformity:

Arm deformity

Forearm deformity

Hand deformity

Thigh deformity

Leg deformity

Foot deformity

Joint Swelling:

Shoulder swelling

Elbow swelling

Wrist swelling

Finger joints swelling

Hip swelling

Knee swelling

Ankle swelling

Toe joints swelling

Joint Deformity:

Shoulder Deformity

Elbow Deformity

Wrist Deformity

Finger joints deformity

Hip Deformity

Knee Deformity

Ankle Deformity

Toe joints deformity

Joint Dislocation:

Shoulder Dislocation

Elbow Dislocation

Wrist Dislocation

Hip Dislocation

Knee Dislocation

Ankle Dislocation

Joint Stiffness:

Shoulder Stiffness

Elbow Stiffness

Wrist Stiffness

Finger joints stiffness

Hip Stiffness

Knee Stiffness

Ankle Stiffness

Toe joints stiffness

Joint Restricted ROM:

Shoulder Restricted ROM

Elbow Restricted ROM

Wrist Restricted ROM

Finger joints Restricted ROM

Hip Restricted ROM

Knee Restricted ROM

Ankle Restricted ROM

Toe joints Restricted ROM

Contracture:

Arm contracture

Forearm contracture

Hand contracture

Thigh contracture

Leg contracture

Foot contracture

Cramps:

Arm cramps

Forearm cramps

Hand cramps

Thigh cramps

Leg cramps

Foot cramps

Proximal myopathy/Movement problems:

difficulty carrying

difficulty combing hair

difficulty raising from chair

difficulty climbing stairs

difficulty going downstairs

difficult dressing

difficulty holding items

difficult driving

Side

Right

Left

Bilateral

For

Sec

Min

Hours

Days

Weeks

Months

Years

In case can’t specify duration:

For Few

Sec

Min

Hours

Days

Weeks

Months

Years

Long-standing

Life-long

Since age

Years Old

Started at

Morning

Noon

Night

Midnight

Onset

Course

Constant

Remittent

Occasional

Recurrent

Persistent

Intermittent

Transient

Duration/episode

Frequency

episodes /

Sec

Min

Day

Week

Month

Years

Unable to enumerate episodes

Varying frequency

Timing

Weather Add New

Exacerbated in

Relieved in

Hot

Cold

Spring

Autumn

Humid

Dry

Rainy

weather

Posture Add New

Exacerbating & Relieving Factors Add New

Breathing

Inspiration

Expiration

Medications

Movement

Other activity

Severity

Mild

Moderate

Severe

Score

/10

Impact

Disrupting sleep

Affecting ADL

Crying

Unable to

during episodes

Worsening severity

Improving severity

Worsening

Improving

throughout the day

varying severity

Score

/10

Score

/10

Score

/10

Variation by day and night

Variation by week and month

Sequencing

Side

Right

Left

Bilateral

For

Sec

Min

Hours

Days

Weeks

Months

Years

In case can’t specify duration:

For Few

Sec

Min

Hours

Days

Weeks

Months

Years

Long-standing

Life-long

Since age

Years Old

Started at

Morning

Noon

Night

Midnight

Onset

Course

Constant

Remittent

Occasional

Recurrent

Persistent

Intermittent

Transient

Duration/episode

Frequency

episodes /

Sec

Min

Day

Week

Month

Years

Unable to enumerate episodes

Varying frequency

Timing

Weather Add New

Exacerbated in

Relieved in

Hot

Cold

Spring

Autumn

Humid

Dry

Rainy

weather

Posture Add New

Exacerbating & Relieving Factors Add New

Breathing

Inspiration

Expiration

Medications

Movement

Other activity

Severity

Mild

Moderate

Severe

Score

/10

Impact

Disrupting sleep

Affecting ADL

Crying

Unable to

during episodes

Worsening severity

Improving severity

Worsening

Improving

throughout the day

varying severity

Score

/10

Score

/10

Score

/10

Variation by day and night

Variation by week and month

Sequencing

Character

Kgs

lbs

weeks

Months

Years

Fever

Cardiovascular

Chest pain

Palpitations

Syncope

Lower limb swelling

Site

Ankle

Leg

Thigh

Intermittent claudication

Orthopnea

How many pillows do you sleep on?

pillows

Night/Rest Pain

Respiratory

SOB

Wheezing

Exacerbated by

Exertion

Cold air

Pollen

Cough

Sputum

Hemoptysis

GI tract

Jaundice

Associated symptoms

itching/pruritis

Normal urine

Dark/brown urine

Normal stool

Pale stool

Fever

Rigors

Abdominal pain

Heartburn

Characters

Associated with acid reflux

Burning

Radiated upwards

Exacerbated by lying flat

Exacerbated by bending forward

Vomiting

Diarrhea

Piles

Characters

Tender

Reduced spontaneously

Reduced manually

Irreducible

Changed stool characters

Constipation

Characters

Associated with pain on defecation

Bowel movement frequency

times/

week

month

History of diet change

Yes

Stool shape change

Yes

Hematemesis

Blood on defecation

Character

Blood on toilet paper

Spots of blood

Blood on the pan

Abdominal pain

Abdominal discomfort

Rectal bleeding

Characters

Mixed with stool

Coat surface of normal stool

Blood on toilet paper

Spots of blood

Blood on the pan

Anorectal pain

Characters

Blood on paper

Blood on defecation

Pain on beginning of defecation

Pain on end of defecation

Pain on entire defecation

Dysphagia

Neuro

Headache

Seizures

Tremors Heaviness Weakness Abnormal movements Paresthesia Tingling Sensory loss Decreased sensation Increased sensation Allodynia Hyperalgesia

Genitourinary

Loin pain

Other sites

Genitalia

Thigh

iliac fossa

Groin

Bladder incontinence

Characters

Urge

Stress

Mixed

Hematuria

Changed urine color

Dark

Brown

Black

Green

Orange

Red

Blue

Pink

Obs & Gyn

Vaginal discharge

Contraception

Vaginal bleeding

Character

Painful

Painless

Menorrhagia

HEENT

Eye pain

Eye discharge

Volume

Large

Moderate

small

Color

Green

Yellow

Content

Clear

Purulent

Blood

Consistency

Watery

Loss of vision

Characters

Complete

Partial

Occipital

Central

Peripheral

Ear discharge

Nasal discharge

Volume

Profuse

Moderate

Minimal

Color

Green

Content

Clear

Purulent

Consistency

Watery

Odor

Offensive

Non-offensive

Musculoskeletal

History

Trauma

Immobilization

Weight bearing

Heavy Exercise/Excessive activity

Activity

Psychiatry

Specific phobia

Character

Head & Neck

Right

Left

Bilateral

Upper

Lower

Eye

Sclera

Conjunctiva

Iris

Pupil

Periorbital area

Eyelid

Eyebrow

Eyelashes

Ear

Pinna

Tragus

Antitragus

Helix

Antihelix

Ear lobule

Periauricular area

External auditory canal

Nose

Nasal bridge

Nasal tip

Nasal septum

Little’s area

Superior turbinate

Middle turbinate

Inferior turbinate

Nasopharynx

Neck

Anterior triangle

Posterior triangle

Thyroid cartilage

Cricoid cartilage

Larynx

Trunk

Neck

Chest

Abdomen

Back

Buttocks

Vertebrae

Cervical

Thoracic

Lumbar

Sacrum

Coccyx

Intervertebral disc

Chest

Right

Left

Bilateral

Sites

Right

Left

Upper

Lower

Areas

Supraclavicular area

Infraclavicular area

Breast

Right breast

Left breast

Bilateral breasts

In the (quadrant)

Upper

Lower

Outer

Female

In the (quadrant)

Axillary tail

Under breast

Nipple

Areola

Lines

Midclavicular line

Anterior axillary line

Mid axillary line

Posterior axillary line

Intercostal Space

Intercostal space

Abdomen Site

Right Side of the abdomen

Left Side of the abdomen

Upper abdomen

Central abdomen

Lower abdomen

Pelvis

Perineum

Pubic region

Buttocks

Anus

Perianal region

Male genitals

Penis

Scrotum

Epididymis

Testis

Seminal vesicles

Prostate

Female genitals

Vulva

Labia majora

Labia minora

Vestibule

Urethra

Vagina

Clitoris

Fourchette

Upper limb

Right

Left

Bilateral

Upper

Lower

Lower limb

Right

Left

Bilateral

Upper

Lower