Medical Chart

  • Patient's identification
    • Date of Entrance:  ,Time:  ,ID:
    • Department:  ,Room:
    • Patient's name:  ,Sex:  ,Age:
    • Nationality:  ,Occupation:
    • Address:
    • Referral from:
  • Chief Complaint
    • Main symptoms that the patient comes to see a doctor
  • History of present illness(HPI)
    • Location:  ,Severity:  ,Duration:  
      • When
      • Progressing, regressing, steady
      • constant, intermittent, frequency
      • aggravating, alleviating, Associated factor
  • Medications
    • Allergic 
    • Currence medication(CM)
  • Past of medical history(PMH)
    • Medications/Vitamins/Herbal(-/-/-)
    • Allergies
    • Operations/Hospitalizations/Blood transfusions(-/-/-) When?How many?Type?
    • Adult patient: DM/HTN/MI/Stroke/Peptic ulcer/Asthma/Emphysema/Thyroid/Liver/Kidney/ Bleeding/Cancer/TB/Hepatitis/STD
      • ask about routine health maintenance
    • Pediatric patient:
  • Past Surgical and OBGYN history
    • Past surgical history: Type, date, pathology
    • OBGYN history(If female): Menarche, Menstrual cycle, Paragravida, abortion
    • Urogenital tract:
      • Urination(difficulty/pain/blood/burning)
      • Frequency: how many times per day?
      • History: UTI/Kidney problem/other(-/-/-)
      • Symptoms: Fever, chills, nausea, vomiting, flank pain(R/L)
  • Family history: 
    • Age, blood relatives
    • Medical problem of blood relatives: cancer(breast, colon, prostate), TB, asthma, MI, HTN, DM, thyroid disease, kidney disease, peptic ulcer, bleeding, Glaucoma, Macular degeneration, depression, and alcohol or substance abuse.
  • Personal history
    • stressors: finance, relationships, work, school
    • patient profile: marital status and children, sexual orientation, present and past employment, financial support and insurance, education, religion. hobbies, belief, living conditions
  • Immunization
    • Childhood and adult vaccinations: Type? (completed or not)
  • Review of systems
    • General appearance: Weight, Fatigue, weakness, appetite, fever, chill, night sweats...
    • Skin: Rashes, pruritus, bruising, dryness, skin cancer or other 
    • Head: Trauma, headache, tenderness
    • Eyes 
    • Nose
    • Necks
    • Throat
    • Gastrointestinal
    • Respiratory
    • Cardiovascular
    • Genecologic
    • Genitourinary
    • Endocrine: polyuria, polydipsia, polyphagia

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