Outline for Patient Interview

Date: ___________ Time: ___________

A. INITIAL INFORMATION
Name: ____________________________________ Age: ____________ Date of Birth: ________________________ Sex: ______________
Address: ______________________________________________ Marital Status: ____________ Occupation: _____________________________
Source of History: ______________________________________ (If referral – source: ___________________________________________________)

B. CHIEF COMPLAINT (CC): ______________________________________________________________________________________________

C. HISTORY OF PRESENT ILLNESS (HPI)
Symptom 1 Symptom 2 Symptom 3
o Onset
o Setting in which it developed
o Associated manifestations
o Location
o Frequency
o Timing
o Character/ Quality
o Severity/ Quantity
o Duration
o Aggravating/ Relieving factors
o Treatment/ Medication
o (Name, Dose, Route, Frequency of use, others ex: home remedies,
vitamins, nonprescription drugs)
C. PAST HISTORY
Childhood Illnesses:
Adult Illnesses Medical (hospitalization, illnesses, sexual practices): _______________________________________________________________________________________
Surgical (types, date, indications): _____________________________________________________________________________________________________
Ob/Gyne (mense history, contraception, sexual function): ___________________________________________________________________________________
Psychiatric (diagnoses, hospitalization etc): ______________________________________________________________________________________________
Health Maintenance Immunizations: ____________________________________________________________________________________________________________________
Screening tests (results, when last performed): ___________________________________________________________________________________________
D. FAMILY HISTORY: (age & health or age & cause of death of immediate family members, present conditions in family, history of cancer etc)
_________________________________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________________________

E. PERSONAL & SOCIAL HISTORY

Allergies (food, medication etc): ________________________________________________________________________________________________________
Tobacco use (pack years): ________________________________________ If quitted, for how long? ________________________________________________
Alcohol and drug use: ________________________________________________________________________________________________________________
o Personality/ interests _______________________ o Religion __________________________________ o Frequent exercise _______________________________
o Occupation ______________________________ o Sources of stress ___________________________ o Daily food intake ________________________________
o Strengths, fears ___________________________ o Important life experiences ____________________ o Dietary supplements _____________________________
o Sources of support ________________________ o Leisure activities ___________________________ o Use of caffeinated drinks __________________________
o Last year of schooling ______________________ o Activities of daily living _______________________ o Alternative health care practices ____________________
F. REVIEW OF SYSTEMS
1. General: 4. Neck 9. Peripheral vascular o Number of pregnancies
o Usual weight o Swollen glands o Intermittent claudication o Number and type of deliveries
o Weight change o Goiter o Leg cramps o Number of abortions
o Fever o Lumps o Varicose veins o Complications of pregnancy
o Fatigue o Pain or stiffness o Past clots in the veins o Birth-control methods
o Weakness 5. Breasts o Swelling in calves/legs/feet o Sexual preference (interest, function,
2. Skin: o Lumps o Color change in fingertips or toes during cold satisfaction, problems, including
o Rashes o Pain/ discomfort weather dyspareunia)
o Lumps o Nipple discharge o Swelling with redness or tenderness o HIV infection
o Sores, Itching o Self-examination 10. Urinary 13. Musculoskeletal
o Dryness 6. Respiratory o Frequency of urination o Muscle or joint pain
o Changes in color; in hair or nails o Cough o Polyuria o Stiffness
o Changes in size or color of moles o Sputum (color, quantity) o Nocturia o Arthritis
3. Head, Eyes, Ears, Nose, Throat (HEENT) o Hemoptysis o Urgency o Gout
o Headache o Dyspnea o Burning or pain during urination o Back- ache (If present, describe
o Head injury o Wheezing o Hematuria location)
o Dizziness o Pleurisy o Urinary infections o Include timing of symptoms, duration
o Lightheadedness o Last chest x-ray o Kidney or ank pain o History of trauma
o Vision o Include asthma, bronchitis, emphysema, o Kidney stones o Neck or low back pain
o Glasses/ contact lenses pneumonia, and tuberculosis o Ureteral colic o Joint pain with systemic features (fever,
o Last examination 7. Cardiovascular o Suprapubic pain chills, rash, anorexia)
o Pain o Heart trouble o Incontinence 14. Psychiatric
o Redness o High blood pressure o In males, reduced caliber or force of the o Nervousness
o Excessive tearing o Rheumatic fever urinary stream, hesitancy, dribbling o Tension
o Double or blurred vision o Heart murmurs 11. Genital (M) o Mood
o Spots o Chest pain/ discomfort o Hernias o Suicide attempts, if relevant
o Specks o Palpitations o Discharge on penis 15. Neurologic
o Ashing lights o Dyspnea/ thopnea o Testicular pain or masses o Changes in mood
o Glaucoma, cataracts o Paroxysmal nocturnal dyspnea o Scrotal pain or swelling o Attention/ Speech
o Hearing o Edema o History of STI and treatments o Changes in orientation
o Tinnitus o Results of past ECGs/ other tests o Sexual habits (interest, function, satisfaction, o Memory
o Vertigo 8. Gastrointestinal birth control methods, condom use, and o Insight/judgment;
o Earaches o Trouble swallowing problems) o Headache
o Infection o Heartburn o HIV infection o Dizziness
o Discharge o Appetite 12. Genital (F) o Vertigo
o If hearing is decreased, use or nonuse of o Nausea o Age at menarche o Fainting/blackouts
hearing aids o Bowel movements o Regularity, frequency, and duration of o Weakness, paralysis
o Frequent colds o Stool color and size periods o Numbness or loss of sensation
o Nasal stufness o Change in bowel habits o Amount of bleeding o Tingling or pins and needles
o Discharge/itching o Pain with defecation o Bleeding between periods or after o Seizures
o Hay fever o Rectal bleeding or black stools intercourse 16. Hematologic
o Nosebleeds o Hemorrhoids o Last menstrual period o Anemia
o Sinus trouble. o Constipation o Dysmenorrhea o Easy bruising or bleeding
o Condition of teeth and gums o Diarrhea o Premenstrual tension o Past transfusions
o Bleeding gums, o Abdominal pain o Age at menopause o Transfusion reactions
o Dentures, if any o Food intolerance o Menopausal symptoms 17. Endocrine
o Last dental exam o Excessive gas o Postmenopausal bleeding o Thyroid trouble
o Sore tongue o Jaundice o *exposure to diethylstilbestrol (DES) o Heat or cold intolerance
o Dry mouth o Liver/ gallbladder trouble o Vaginal discharge o Excessive sweating
o Frequent sore throats o Hepatitis o Itching o Excessive thirst or hunger
o Hoarseness o Sores/lumps o Polyuria
o History of STI and treatments o Change in glove/shoe size
 G. Physical Examination
1. General Survey (Observe) 9. Anterior Thorax and Lungs
o State of health __________________________________________ o Inspect, palpate, and percuss the chest ____________________________________
o Height ________________________________________________ o Listen to the breath sounds ______________________________________________
o Built __________________________________________________
o Sexual development _____________________________________ 10. Cardiovascular System
o Patient’s weight _________________________________________ o Observe jugular venous pulsations ________________________________________
o Note posture, motor activity, and gait _________________________ o Measure the jugular venous pressure (relate to sternal angle)
o Dress, grooming, and personal hygiene ______________________ ____________________________________________________________________
o Odors of the body or breath ________________________________ o Palpate the carotid pulsations ____________________________________________
o Watch facial expressions __________________________________ o Listen for carotid bruits _________________________________________________
o Note manner, affect, and reactions __________________________ o Inspect and palpate the precordium _______________________________________
o State of awareness or level of consciousness __________________ o Location, diameter, amplitude, and duration of the apical impulse ________________
____________________________________________________________________
2. Vital Signs o Listen at each auscultatory area __________________________________________
o Blood pressure __________________________________________ o Listen at the apex and the lower sternal border with the bell ____________________
o Pulse __________________________________________________ ____________________________________________________________________
o Respiratory rate _________________________________________ o Listen for the rst and second heart sounds __________________________________
o Body temperature ________________________________________ o Abnormal heart sounds or murmurs ________________________________________

3. Skin 11. Abdomen

o Assess skin moisture, dryness, temp _________________________ o Percuss the abdomen __________________________________________________
o Lesions (location, distribution, arrangement, type, and color) o Palpate lightly, then deeply ______________________________________________
_______________________________________________________ o Assess the liver and spleen by percussion and then palpation ___________________
o Inspect hair and nails _____________________________________ ____________________________________________________________________
o Study hands ____________________________________________ o Feel the kidneys _______________________________________________________
o Palpate aorta and its pulsations ___________________________________________
4. Head, Eyes, Ears, Nose, Throat (HEENT) o If kidney infection, percuss posteriorly over the costovertebral angles _____________
o Examine hair, scalp, skull, and face __________________________
o Visual acuity ____________________________________________ 12. Lower Extremities
o Screen the visual elds ____________________________________ o Examine the legs ____________________________________________________
o Position and alignment of eyes _____________________________ o With the patient supine:
o Observe eyelids _________________________________________ o Palpate the femoral pulses _________________________________________
o Inspect the sclera and conjunctiva ___________________________ o Popliteal pulses __________________________________________________
o With oblique lighting, inspect each cornea, iris, and lens o Palpate inguinal lymph nodes _______________________________________
______________________________________________________ o Lower extremity edema, discoloration, or ulcers _________________________
o Compare the pupils, test their reactions to light _________________ o Palpate for pitting edema __________________________________________
_______________________________________________________ o Note deformities or enlarged joints ___________________________________
o Assess the extraocular movements __________________________ o Assess muscle bulk, tone, and strength _______________________________
o Inspect the ocular fundi (ophthalmoscope) _____________________ o Sensation and reflexes ____________________________________________
o Inspect the auricles, canals, and drums _______________________ o Observe abnormal movements ______________________________________
o Auditory acuity __________________________________________ o With the patient standing:
o If acuity is diminished, check lateralization (weber test) o Varicose veins ___________________________________________________
_______________________________________________________ o Alignment of spine ________________________________________________
o Compare air and bone conduction (rinne test) __________________ o Range of motion _________________________________________________
o Examine the external nose _________________________________ o Alignment of the legs and feet ______________________________________
o Inspect the nasal mucosa, septum, turbinates __________________ o Examine penis and scrotal contents __________________________________
o Palpate for tenderness of frontal, maxillary sinuses ______________ o Check for hernias ________________________________________________
o Inspect the lips, oral mucosa, gums, teeth, tongue, palate, tonsils, o Observe gait and ability to walk ______________________________________
and pharynx ____________________________________________ o Romberg test and check for pronator drift. _____________________________
o Assess the cranial nerves _________________________________
13. Nervous System
5. Neck o Mental status. If indicated and not done during the interview, assess the patient’s
o Palpate cervical lymph nodes _______________________________ orientation, mood, thought process, thought content, abnormal perceptions, insight
o Note unusual pulsations ___________________________________ and judgment, memory and attention, information and vocabulary, calculating
o Feel any deviation of the trachea ____________________________ abilities, abstract thinking, and constructional ability
o Sound and effort of the patient’s breathing _____________________ __________________________________________________________________
o Palpate the thyroid gland __________________________________ __________________________________________________________________
o Cranial nerves. If not already examined, sense of smell, strength of the temporal
6. Back and masseter muscles, corneal reflexes, facial movements, gag reflex, and strength
o Palpate the spine and muscles of the back ____________________ of the trapezia and sternomastoid muscles
o Shoulder height for symmetry ______________________________ __________________________________________________________________
__________________________________________________________________
7. Posterior Thorax and Lungs o Motor system. Muscle bulk, tone, and strength of major muscle groups. Cerebellar
o Palpate the spine and muscles of the upper back _______________ function: rapid alternating movements (rams), point-to-point movements
_______________________________________________________ __________________________________________________________________
o Percuss the chest ________________________________________ __________________________________________________________________
o Identify level of diaphragmatic dullness on each side o Sensory system. Pain, temperature, light touch, vibration, and discrimination
_______________________________________________________ __________________________________________________________________
o Listen to the breath sounds ________________________________ o Reflexes. Biceps, triceps, brachioradialis, patellar, achilles deep tendon reflexes,
o Identify any adventitious (or added) sounds ____________________ plantar or babinski reflex ______________________________________________
__________________________________________________________________
8. Breasts, Axillae, and Epitrochlear Nodes
o (W) inspect breasts with arms relaxed à elevated à pressed on her 14. Additional Examinations
hips ___________________________________________________ o Men. Sacrococcygeal and perianal areas. Palpate anal canal, rectum, and prostate
o Inspect the axillae ________________________________________ __________________________________________________________________
o Feel for the axillary nodes __________________________________ o Women. Examine external genitalia, vagina, and cervix. Obtain a pap smearPalpate
o Feel epitrochlear nodes ___________________________________ the uterus and adnexa bimanually
__________________________________________________________________

CLINICAL EVALUATION
GROUP 9