GGeneral Survey

1.       Age, race, sex, Ht, Wt

2.       Reason for seeking care

3.       HX present illness with Critical characteristics: location, character & quality, severity timing, setting,  aggravating or relieving assoc. factors, perceptions.

4.       Past health: operations, hospitalizations, immunizations

5.       Pertinent family health (cancer, heart disease, diabetes)

6.       Cultural background

MMental Status

1.       Person, place, time, situation

SSkin, Hair, Nails

1.       Previous HX skin disease (allergies, hives, psoriasis, eczema, dermatitis, cancer)

2.       Change in pigmentation

3.       Pruritis

4.       Excessive bruising

5.       Rash or lesions

6.       Hair loss

7.       Change in nails

8.       Environmental or occupational hazards

9.       Self-care behaviors

EENT

1.       Visual difficulty (decreased acuity, blurring, blind spots)

2.       Eye pain, redness or swelling

3.       Watering or discharge

4.       HX injury or eye surgery

5.       Glaucoma

6.       Glasses or contacts, last vision test

7.       Ringing in ears

8.       Earache, ear infection, discharges; Hearing loss

9.  Environmental noise

10. Last hearing test

11. Nasal discharge

12. Frequent colds

13. Sinus pain

14. Nasal trauma, nosebleeds

15. Altered smell

16. Mouth sores or lesions

17. Sore throats;  Bleeding gums;  Gingivitis; Toothache; Voice changes

18. Dysphagia

19.  Daily dental care, dentures

Heart & Neck Vessels

1.       Chest pain

2.       Dyspnea on exertion

3.       Orthopnea

4.       Fatigue

5.       Cyanosis or pallor

6.       Edema

7.       Past cardiac HX

8.       Family cardiac HX

9.       Personal cardiac risk factors (BP, obesity, diabetes, smoking, alcohol, sedentary lifestyle)

10.     HX chronic emphysema, bronchitis

11.     Cardiac medications