MODIFIED TESTED AND APPROVED 2025/2026
NEW UPDATE
History of the patient
How can I help you today?
Do you have any allergies, such as medications, food and/or latex, for
example?
Do you have any other symptoms or concerns we should discuss?
Are you taking any prescription medications?
Are you taking any over-the-counter or herbal medications?
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,Can you tell me about any current or past medical problems you have
had?
Any previous medical, surgical, or dental procedures?
Do you now or have you ever smoked or chewed tobacco?
Have you had any contact with other sick people?
Are you sexually active?
Do you experience: chest pain discomfort or pressure;
pain/pressure/dizziness with exertion or getting angry; palpitation;
decreased exercise tolerance; blue/cold fingers or toes?
Do you have any of the following: dizziness, fainting, spinning room,
seizures, weakness, numbness, tingling, tremor?
Do you have any of the following problems: fatigue, difficulty sleeping,
unintentional weight loss or gain, fevers, night sweats?
How high was your fever?
When you urinate, have you noticed: pain, burning, blood, difficulty
starting or stopping, dribbling, incontinence, urgency during day or
night or any changes in frequency?
How severe (1-10) is the pain in your chest?
Do you have any pain in your chest?
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, Have you noticed: any bruising, bleeding gums, nose bleeds or other
sites of increased bleeding?
Do you have any of the following: heat or cold intolerance, increased
thirst, increased sweating, frequent urination, change in appetite?
Do you have any problems with: nervousness, depression, lack of
interest, sadness, memory loss, or mood changes, or ever hear
voices or see things that you know are not there?
Do you awaken at night coughing?
What treatments have you had for your cough?
What are the events surrounding the start of your cough?
Is there any pattern to your cough?
Does anything make your cough better or worse?
Do you have HIV?
Do you drink alcohol? If so, what do you drink and how many
drinks per day?
Have you had a cough like this before?
Do you have problems with: nausea, vomiting, constipation, diarrhea,
coffee grounds in your vomit, dark tarry stool, bright red blood in
your bowel movements, early satiety, bloating?
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