Health Hx:
P: PMH to include previous illness, and state of health
L: last oral intake of liquids and food
E: Events leading to illness or injury
A: allergies and the type of reactions
S: symptoms or chief complaint
E: each prescribed medication, OTC medications, and herbal supplements
🟦 1. OVERVIEW & DOCUMENTATION
(START HERE)
● Record date & time of interview
● Document client’s preferred language
○ Use professional interpreter if needed (NOT family/friends)
● Speak directly to client, short sentences, avoid medical jargon
● Document source of info (client, family, interpreter, records)
🔑 Biographic Data
● Name, DOB, age, address, phone
● Emergency contact
● Gender identity + pronouns (respect privacy)
● Ask about disabilities affecting ADLs
🔑 Chief Complaint (CC)
● Document in client’s OWN WORDS (quotes)
● Include duration
● Example: “Low back pain x 2 weeks”
🔑 History of Present Illness (HPI)
Use ⭐ OLD CARTS
● O – Onset
● L – Location
● D – Duration
, ● C – Characteristics
● A – Aggravating/Alleviating
● R – Related symptoms
● T – Treatment
● S – Severity
🔑 Social Determinants of Health
● Economic stability
● Education
● Healthcare access
● Environment
● Social/community support
🟦 2. GENERAL MEDICAL HISTORY
🔑 Ask about:
● Childhood illnesses (measles, mumps, etc.)
● Injuries (fractures, burns, head trauma)
● Chronic diseases (DM, asthma, seizures)
● Hospitalizations & surgeries
● Immunizations (CDC guidelines)
● Health screenings (colonoscopy, Pap smear, TB, cholesterol)
● Allergies (TRUE reactions only)
● Medication reconciliation
○ Rx + OTC + supplements + herbs
● Nutrition & weight changes
🔑 Obstetric (GTPAL)
● G = pregnancies
● T = term
● P = preterm
● A = abortions
● L = living children
🔑 Psychosocial
P: PMH to include previous illness, and state of health
L: last oral intake of liquids and food
E: Events leading to illness or injury
A: allergies and the type of reactions
S: symptoms or chief complaint
E: each prescribed medication, OTC medications, and herbal supplements
🟦 1. OVERVIEW & DOCUMENTATION
(START HERE)
● Record date & time of interview
● Document client’s preferred language
○ Use professional interpreter if needed (NOT family/friends)
● Speak directly to client, short sentences, avoid medical jargon
● Document source of info (client, family, interpreter, records)
🔑 Biographic Data
● Name, DOB, age, address, phone
● Emergency contact
● Gender identity + pronouns (respect privacy)
● Ask about disabilities affecting ADLs
🔑 Chief Complaint (CC)
● Document in client’s OWN WORDS (quotes)
● Include duration
● Example: “Low back pain x 2 weeks”
🔑 History of Present Illness (HPI)
Use ⭐ OLD CARTS
● O – Onset
● L – Location
● D – Duration
, ● C – Characteristics
● A – Aggravating/Alleviating
● R – Related symptoms
● T – Treatment
● S – Severity
🔑 Social Determinants of Health
● Economic stability
● Education
● Healthcare access
● Environment
● Social/community support
🟦 2. GENERAL MEDICAL HISTORY
🔑 Ask about:
● Childhood illnesses (measles, mumps, etc.)
● Injuries (fractures, burns, head trauma)
● Chronic diseases (DM, asthma, seizures)
● Hospitalizations & surgeries
● Immunizations (CDC guidelines)
● Health screenings (colonoscopy, Pap smear, TB, cholesterol)
● Allergies (TRUE reactions only)
● Medication reconciliation
○ Rx + OTC + supplements + herbs
● Nutrition & weight changes
🔑 Obstetric (GTPAL)
● G = pregnancies
● T = term
● P = preterm
● A = abortions
● L = living children
🔑 Psychosocial
