CLINICAL HISTORY TAKING STRUCTURE II (STEP 4 AND 5)
PAST MEDICAL HISTORY(PMHx)
HAVE YOU EVER HAD OR DO YOU HAVE A MAJOR ILLNESS?
HAVE YOU EVER HAD A MAJOR INJURY?
HAVE YOU EVER HAD ANYTHING LIKE THIS BEFORE?
ARE YOU ALLERGIC TO ANY FOOD OR ANYTHING ELSE?
NOW I’M GOING TO ASK YOU ABOUT YOUR HEALTH IN THE PAST
HAVE YOU EVER HAD MAJOR SURGERY/A MAJOR OPERATION?
NOW I’M GOING TO ASK YOU ABOUT YOUR HEALTH IN GENERAL.
DRUG HISTORY(DHx)
DO YOU TAKE ANY VITAMINS OR OTHER SUPPLEMENTS?
ASKING FOR DETAIL:
DO YOU TAKE ANY HERBAL MEDICINE?
WHAT MEDICATION DO YOU TAKE?
DO YOU TAKE ANY OVER-THE-COUNTER DRUGS?
WHAT DO YOU TAKE IT FOR?
ARE YOU TAKING ANY MEDICATIONS AT THE MOMENT?
HOW MANY TIMES A DAY DO YOU TAKE IT?
ALLERGIES TO MEDS
DO YOU HAVE ANY SIDE EFFECTS?
INCLUDE DOSAGE AND HOW OFTEN THEY ARE TAKING THEM.
WHAT DRUGS ARE YOU ALLERGIC TO?
FIND OUT WHAT MEDICATIONS(MEDS) THE PATIENT IS TAKING.
WHAT SYMPTOMS DO YOU GET?
NOW I AM GOING TO ASK YOU ABOUT YOUR FAMILY’S HEALTH:
DOES ANYONE IN YOUR FAMILY HAVE A SERIOUS ILLNESS?
ARE YOUR PARENTS ALIVE AND WELL?
HOW OLD WAS HE/SHE WHEN HE/SHE DIED?
DO YOU KNOW THE CAUSE OF DEATH?
SOCIAL HISTORY(SHx)
DO YOU HAVE ANY CHILDREN?
WHO DO YOU LIVE WITH?
IS THERE ANY STRESS AT HOME?
DO YOU WORK?
DO YOU HAVE A PARTNER?
DO YOU SMOKE?
EVERYTHING WE TALK ABOUT IS CONFIDENTIAL.
HOW MANY A DAY?
NOW I AM GOING TO ASK YOU SOME PERSONAL QUESTIONS.
DO YOU USE RECREATIONAL DRUGS?
DO YOU DRINK?/ HOW MUCH DO YOU DRINK A WEEK?