Identifying Data: Patient's name; age, race, sex. List the patient's significant medical problems. Name of informant (patient, relative).
Chief Compliant: Reason given by patient for seeking medical care and the duration of the symptom. List all of the patients medical problems.
History of Present Illness (HPI): Describe the course of the patient's illness, including when it began, character of the symptoms, location where the symptoms began; aggravating or alleviating factors; pertinent positives and negatives. Describe past illnesses or surgeries, and past diagnostic testing.
Past Medical History (PMH): Past diseases, surgeries, hospitalizations; medical problems; history of diabetes, hypertension, peptic ulcer disease, asthma, myocardial infarction, cancer. In children include birth history, prenatal history, immunizations, and type of feedings.
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