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The medical history, case history, or anamnesis (from Greek: ἀά, an, open, and ή, mnesis, memory) of a patient is a set of information the physicians collect over medical interviews.
In general, a medical history includes an inquiry into the patients medical history, past surgical history, family medical history, social history, allergies, and medications the patient is taking or may have recently stopped taking.
The Social history section on the patient Summary contains data elements including, tobacco use, alcohol use, financial resources, education, physical activity, stress, social isolation and connection, and exposure to violence.
Questions about past illnesses What illnesses or diseases have you had in the past? Since your initial diagnosis and treatment, have your illnesses returned? How has the illness impacted your daily life and activities? What medical care did you get for the illness? When did you first notice the diseases symptoms?
Medical History Form. Record all past and/or concomitant medical conditions or surgeries. Record only one condition or surgery per line using the codes provided in the table. When recording a condition and surgery related to that condition use one line for the condition and one line for the surgery.
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Create a Checklist Greet patients and introduce yourself. Ask why the patient is being seen. Inquire about previous medical and surgical history. Ask about allergies and current medications. Request information about family medical history. Ask about social history, as well as smoking and drinking.
The History and Physical Exam, often called the HP is the starting point of the patients story as to why they sought medical attention or are now receiving medical attention.
Create a Checklist Greet patients and introduce yourself. Ask why the patient is being seen. Inquire about previous medical and surgical history. Ask about allergies and current medications. Request information about family medical history. Ask about social history, as well as smoking and drinking.

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