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Generally speaking, most patient history conversations are as follows: Greet the patient by name and introduce yourself. Ask, What brings you in today? and get information about the presenting complaint. Collect past medical and surgical history, including any allergies and any medications theyre currently taking.
Frequently used opening questions include, What problems brought you to the hospital (or office) today? or What kind of problems have you been having recently? or What kind of problems would you like to share with me? These open-ended, nondirective questions encourage the patient to report any and all problems.
History of Present Illness o When did it start / how long has it been going on? o Is this a new problem / first time having this problem? o Intermittent or constant? o What makes it worse Any other symptoms that you have?
Please list any past medical history below with date of onset or diagnosis. Examples include asthma, diabetes, depression, anxiety, drug or alcohol dependency, high blood pressure, thyroid disease, autoimmune disease, chronic pain, gynecologic disorder. Have you ever had surgery?
Please list any past medical history below with date of onset or diagnosis. Examples include asthma, diabetes, depression, anxiety, drug or alcohol dependency, high blood pressure, thyroid disease, autoimmune disease, chronic pain, gynecologic disorder. Have you ever had surgery?
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Please indicate if YOU have a history of the following: ■ Alcohol Abuse. ■ I am adopted and do not know biological family history. heart disease before the age of 55. ■ List additional drugs on back of questionnaire. Allergies. ■ I have no known drug allergies.
History of Present Illness o When did it start / how long has it been going on? o Is this a new problem / first time having this problem? o Intermittent or constant? o What makes it worse Any other symptoms that you have?
Some instances may allow for a few questions, at which time, the 3 primary questions to ask the patient are about the patients general and brief medical history, allergies, and medications the patient is currently or recently has been taking.

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