History Taking Pd1

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Knock Greet w/ smile Introduce Is it okay if I take a history? What brings you in today? Is there something else? Can you please tell me more about ____? Would you like to tell me more about ____? Anything else? Summarize (please let me know if I get anything wrong) Now, if you don’t mind, I’d like to ask you a few more questions to help me better understand what is going on with you, is that okay? Could you tell me when this happened/occurred? Progression? Has it gotten worse? Location? Radiation/Spreading? Quality (sharp/dull/achy)? Severity (1-10) Aggravated by? Relieving by? Have you noticed any swelling or other symptoms that you would like me to take note of? Could you please tell me what you were thinking when this first happened? Could you please also tell me how the symptoms have affected your life? Summarize I am going to ask you a few questions about your medical history Childhood illness? Any recent hospitalizations? Medications? Allergies? I am going to ask you a few questions about family, if that is okay with you? Does your mother/father have any current illness How about your siblings? I am going to ask a few questions about your personal life and activities? Do I have your permission? Married? Kids? Smoking? Alcohol? CAGE (Cut down, annoyed, guilty, eye-opener) Diet? Exercise? Occupation?

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Current stress level? Travel? Sexual? I am going to ask you a few more questions? Headache? Pain with ear/face Shoulder? Arm? Legs? Feet? SUMMARIZE. Questions? Shake hands/secure consent