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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