SAINT LOUIS UNIVERSITY
SCHOOL OF MEDICINE
DEPARTMENT OF MEDICINE
GENERAL DATA:
Name:___________________________________________________________________
Address: _______________________________________________________________
Age: __________ Sex: ______ Birthdate: ________________Race: ___________
Religion: __________ Marital Status: ________Occupation: _____________
Informant: _________________________________Reliability: ____________%
CHIEF COMPLAINT:
HISTORY OF PRESENT ILLNESS:
Onset: _____________________________________________________________________
Precipitating factors: _____________________________________________________
Quality: ____________________________________________________________________
Radiation: _________________________________________________________________
Relieving factors: _________________________________________________________
Drug. Dosage, effect (if any): ____________________________________________
Severity/Setting: _________________________________________________________
Timing/Duration/Frequency: ___________________________________________
Location: __________________________________________________________________
Associatedmanifestations/symptoms:_________________________________________
____________________________________________________________________________________
_______________________________________________________________
PAST MEDICAL HISTORY:
Childhood Illnesses (if relevant): _______________________________________
Adult diseases: ____________________________________________________________
Treatment: ________________________________________________________________
Previous confinements: __________________________________________________
Surgeries/year: ___________________________________________________________
Adult Vaccinations: _______________________________________________________
Lab test/results: __________________________________________________________
Allergies: __________________________________________________________________
OB-GYNE HISTORY:
(for all female patients):
LMP: _______________________________________________________________________
OB score: Gravida_____Parity_____
Term_____Preterm_____Abortion_____ Living _____
(if relevant):
Duration of menses: _____________No. of pads per day: _________________
Dysmenorrhea: __________ Family Planning method: ___________________
Papsmear: __________ Last sexual contact: _______________________________
No. of sexual partner/s: __________ Age of menopause: _________________
FAMILY HISTORY:
Heredofamilial diseases: _________________________________________________
Immediate family member with heredofamilial diseases:
____________________________________________________________________________________
______________________________________________________________________
Deceased immediate family members:
_____________________________________________________________________________
Age and Cause of death: _________________________________________________
PERSONAL AND SOCIAL HISTORY:
Smoking (Y/N): _______ Sticks/day: _______ Years of smoking: _________
Quit smoking at age or year: ______________Drinking(Y/N):_____________
Type of alcoholic beverage/Amount/Frequency per week:
_____________________________________________________________________________
Source of drinking water: _______________________________________________
Garbage disposal: ________________________________________________________
Type of toilet: ____________________________________________________________
History of travel: _________________________________________________________
Exposure to endemic diseases: _________________________________________
Dietary preference: ______________________________________________________
Active or sedentary ______________________________________________________
REVIEW OF SYSTEMS: (Choose 5 symptoms per system)
General: ( ) weight change ( ) fever ( ) weakness ( ) pain
Skin: ( ) rashes ( ) lumps ( ) sores ( ) itching ( ) dryness
HEENT: ( ) headache ( ) trauma ( ) dizziness ( ) blurred vision ( ) glasses
or contact lenses ( ) eye redness ( ) diplopia ( ) cataracts ( ) tinnitus ( )
eye/ear/nose discharge ( ) hearing loss ( ) colds ( ) epistaxis ( ) gum
bleeding ( ) sore throat ( ) hoarseness ( ) goiter ( ) neck stiffness ( )
swollen glands
Breasts: ( ) lumps ( ) pain ( ) nipple discharge
Respiratory: ( ) cough ( ) sputum (color, quantity) ( ) hemoptysis ( )
dypsnea ( ) wheezing ( ) pleurisy
Cardiovascular: ( ) chest pain ( ) palpitations ( ) dyspnea ( ) orthopnea (
) paroxysmal nocturnal dyspnea ( ) edema
Gastrointestinal: ( ) dysphagia ( ) heartburn ( ) anorexia ( ) vomiting ( )
constipation ( ) diarrhea ( )abdominal pain ( ) melena ( ) hematochezia (
) jaundice
Peripheral Vascular: ( ) intermittent claudication ( ) leg cramps ( )
edema ( ) varicose veins
Genitourinary: ( ) dysuria ( ) hematuria ( ) nocturia ( ) oliguria ( )
frequency ( ) hesitancy ( ) dribbling ( ) discharge ( ) dyspareunia
( ) vaginal pruritus ( ) vaginal bleeding
Musculoskeletal: ( ) muscle or joint pain ( ) stiffness, ( )weakness ( )
limitation of motion ( ) trauma
Neurologic: ( ) change in speech ( ) change in orientation ( ) weakness ( )
numbness or loss of sensation ( ) tingling or “pins and needles”, ( )
seizures
Psychiatric (if relevant): ( ) nervousness ( ) tension ( ) depression ( )
memory change ( ) suicide attempts