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