Subjective

Question 1

How do you walk in?

Answer 1

1. Walk in and use hand sanitizer (Don’t ask the pt how they are doing yet!)
2. Use their name and yours
3. Shake their hand
4. Sit down

Note: It is very important not to ask how they are before you do these steps.

Question 2

3 open-ended questions

Answer 2

1. What brings you in today?
2. I’m sorry to hear that - Can you tell me more about that?
3. (Oh wow/okay/my goodness/alright) Before I ask you more about that, is there anything else you wanted to bring up today?

Question 3

OLDCA/ARTS

Answer 3

1. When did it start?
2. Where is it located?
3. Is it continuous?
4. Can you describe it the pain for me?
5. Do you have any other things going along with this pain? (I would skip this question because it is your ROS questions)
6. Does anything make it better?
7. Does anything make it worse?
8. Is it worse any particular time of day?
9. How would you rate the pain?

Question 4

M/MAISHIFT

Answer 4

1. Do you have any medical illnesses?
2. Do you take any medications? OTC? Herbals?
3. Are you allergic to any medications?
4. Are your immunizations up to date?
5. Have you ever had any surgeries?
6. Any hospitalizations?
7. Any injuries?
8. Do you have any family hx for any medical problems?
9. Any recent travel?

Question 5

HORSES

Answer 5

1. Do you use any tobacco?
2. How about alcohol?
3. Any recreational drugs?
4. Caffeine consumption?
5. Exercise?
6. What do you do for a living?
7. Do you live with anyone else?
8. Are you sexually active? Do you have any concerns in that area?
9. Do you feel safe in your relationship?
10. Are you exposed to any smoke or toxins at home or at work?
11. Do you have any religious beliefs that would prevent me from treating you?

Question 6

ROS areas

Answer 6

• General
• Head
• Ears
• Eyes
• Nose/Sinuses
• Mouth, Throat, Neck
• Breasts
• Cardiac
• Respiratory
• GI
• Urinary
• Genitals
• Female
• Musculoskeleta
• Vascular
• Psychiatric
• Hematologic
• Endocrine
• Neurologic

Question 7

General

Answer 7

Fatigue, Weakness, Fever/Chills, Night Sweats, Weight Changes

Question 8

Skin

Answer 8

Rashes, Sores, Lumps

Question 9

Head

Answer 9

Trauma, Headache, Visual changes

Question 10

Ears

Answer 10

Hearing loss, Drainage, Ringing

Question 11

Eyes

Answer 11

Glasses/Contacts, Itchy, Blurriness

Question 12

Nose/Sinuses

Answer 12

Runny nose, Congestion, Sneezing

Question 13

Mouth, Throat, Neck

Answer 13

Bleeding Gums, Sore Throat, Trouble swallowing

Question 14

Breasts

Answer 14

Lumps, Pain, Discharge

Question 15

Cardiac

Answer 15

Chest pain, Palpitations, last EKG

Question 16

Respiratory

Answer 16

Trouble breathing, Wheeze, Cough

Question 17

GI

Answer 17

Nausea/Vomiting, Diarrhea/Constipation, Bleeding

Question 18

Urinary

Answer 18

Frequency, Urgency, Hesitancy, Bleeding, Incontinence, Getting several times at night to urinate

Question 19

Genital

Answer 19

Discharge, Sores, Pain, Lumps

Question 20

Female

Answer 20

Age of menarche, period regularity, last menstrual period, discharge, hot flashes, night sweats

Question 21

General sexual

Answer 21

STD hx, Dysfunction, contraception methods

Question 22

Vascular

Answer 22

Leg edema, Pain that’s worse with use (Claudication)

Question 23

MSK

Answer 23

Weakness, Pain, Joint stiffness, Swelling

Question 24

Neurologic

Answer 24

Numbness, Tingling, Tremors

Question 25

Hematologic

Answer 25

Anemia, Easy Bruising/Bleeding

Question 26

Endocrine

Answer 26

Heat/Cold intolerance, Excessive sweating

Question 27

Psychiatric

Answer 27

Anxiety, Depression, Trouble remembering things

Question 28

What should you do before starting your history taking?

Answer 28

Drape the patient!!

Question 29

What do you need to make sure you ask every patient?

Answer 29

Ask how have they been doing with all of this? (aka. how are they coping) Also, as separate questions ask practically -- aka. How has this affected home, work, driving, etc. (need to ask 3+ of these and doctor note counts as 1) (HEY - asks these with occupational hx. Are you able to go to work? How is it affecting your work? Do you need a doctors note?)

Question 30

Make sure to assess health literacy

Answer 30

- What do you know about ..... - Do you know anyone with .....

Question 31

Ask several times if they have any questions

Answer 31

Not just in the closing So like, do you have any questions for me so far? At the end - we sure have covered a lot today - do you have any questions