|
Chief Complaint
|
Onset
|
|
Add. Complaint
|
Onset
|
|
Add. Complaint
|
Onset
|
|
HPI
|
Palliative/Provocative
|
|
Quality, Duration, Frequency
|
Region/Radiation
|
|
Severity
|
Timing
|
|
Associated Symptoms
|
Patient's Explanation of Cause
|
|
Past/Current TX
|
TX Concerns/Expectations
|
|
Family HX
|
Past Medical HX
|
|
Social HX
|
|
|
|
|
|
Temp [-]
|
Temp [+]
• • •
|
|
Temp Comments
|
|
|
Perspiration [-]
|
Perspiration [+]
• • •
|
|
Perspiration Comments
|
|
|
Skin/Hair [-]
|
Skin/Hair [+]
• • •
|
|
Skin/Hair Comments
|
|
|
HA/Dizziness [-]
|
HA/Dizziness [+]
• • •
|
|
HA/Dizziness Comments
|
|
|
EENT/Phlegm [-]
|
EENT/Phlegm [+]
• • •
|
|
EENT/Phlegm Comments
|
|
|
Chest, CV, RESP [-]
|
Chest, CV, RESP [+]
• • •
|
|
Chest, CV, RESP Comments
|
|
|
MSK [-]
|
MSK [+]
• • •
|
|
MSK Comments
|
|
|
Appetite/Thirst [-]
|
Appetite/Thirst [+]
• • •
|
|
Appetite/Thirst Comments
|
|
|
Digestion [-]
|
Digestion[+]
• • •
|
|
Digestion Comments
|
|
|
Stool [-]
|
Stool [+]
• • •
|
|
Stool Comments
|
|
|
Urinary [-]
|
Urinary [+]
• • •
|
|
Urinary Comments
|
|
|
Reproductive (Female) [-]
|
Reproductive (Female) [+]
• • •
|
|
Reproductive (Female) Comments
|
|
|
Reproductive Male (Male) [-]
|
Reproductive (Male) [+]
• • •
|
|
Reproductive (Male) Comments
|
|
|
Energy Level
• • •
|
Energy Comments
|
|
Sleep [-]
|
Sleep [+]
• • •
|
|
Sleep Comments
|
|
|
Mental/Emotional [-]
|
Mental Emotional Comments
|
|
Diet
|
Exercise
|
|
Activities
|
|
