Student:
Date:
| Possible Points | Actual Points | Comments |
|---|
| Identifying Information | 2 | | |
|---|
| • Initials | | | |
|---|
| • Date of Birth | | | |
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| • Age | | | |
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| • Race | | | |
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| • Sex | | | |
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| • Historian | | | |
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| History |
| Chief Complaint | 5 | | |
|---|
| HPI (History of Present Illness) | | | |
|---|
| OLDCARTS | | | |
|---|
| • O- Onset | | | |
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| • L- Location | | | |
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| • D- Duration | | | |
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| • C- Character | | | |
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| • Aggravating/associated/modifying factors | | | |
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| • R- Relieving factors | | | |
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| • T- Temporal factors | | | |
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| • S- Severity | | | |
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| • Quality, timing, & context | | | |
|---|
| Allergies | 1 | | |
|---|
| Meds, Food, Latex, Environmental | | | |
|---|
| Medications (Duration, frequency, reason) | 2 | | |
|---|
| Prescription, OTC, Supplements/Herbals, | | | |
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| Cannabis | | | |
|---|
| Biographic: | 1 | | |
|---|
| Past History | | | |
|---|
| -Medical | | | |
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| -Surgical | | | |
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| Family History | 1 | | |
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| Complete FH for comprehensive examinations | | | |
|---|
| Relevant medical history of relatives addressed | | | |
|---|
| Social History | 2 | | |
|---|
| 1. Tobacco-type, quantity, duration | | | |
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| 2. Alcohol use—CAGE, AUDIT-C when appropriate | | | |
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| 3. Illicit substances | | | |
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| 4. Social support system-family, friends, partners, | | | |
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| relationships, deployment | | | |
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| 5. Recent Travel | | | |
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| 6. Sleep Pattern | | | |
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