Biographic and demographic data:
Health History
Biographic and demographic data:
Name/Address etc
Age
Gender
Ethnic/cultural background
Marital status
Occupation
GP Presenting complaint/reason for consultation: History of Presenting Complaint:
Patients description of problem
Detailed chronological picture of current symptoms/clinical issues Previous Medical History:
Childhood illnesses
Previous injuries
Previous hospitalisations
Previous surgery/major illnesses
Previous treatment
Obstetric history
Developmental hx
Psychiatric history including treatment Current medications and allergies
Complementary/ OTC:
Dispensing history Family Medical History:
Any close contact communicable disease
Blood relatives familial tendency
Age & health status/ deaths/ age/cause of death
Long term health conditions of relevance eg. Diabetes Mellitus, Cardiovascular disease, stroke etc.
Cancer/ Personal and Social history:
Ability of patient to cope with illness or problem
Dependents
Family/social support
Employment
Stressors
Spiritual History HEARTS (younger children)
Home
Education
Activities
Relationships
Temper
Size
HEEADSSS (adolescents)
Home
Education/Employment
Eating
Activities/ambition
Drugs
Sexuality
Suicide/mood/depression
Safety Health risk assessment:
Smoking
ETOH/Drugs
Risk taking behaviours
CVD/diabetes/hypertension risk factors
BMI
Immunisation status
Relevant screening (breast, cervical, prostate, bowel) Review of Systems (subjective from questions, further relevant history relating to PC for each system)
Start considering differential diagnoses based on history then ask some more specific questions.
Make sure there are no RED FLAGS that would warrant terminating the consultation and providing immediate care.
General: HEENT:
e.g. conjunctivitis, otalgia, rhinorrhoea. CVS:
e.g. SOB on exertion or when supine, palpitations. Respiratory:
e.g. cough, wheeze, SOB, ability to talk. Gastrointestinal:
e.g. nausea, vomiting, diarrhoea, stool pattern. Genitourinary:
e.g. dysuria, urinary frequency, discharge. Endocrine:
e.g. Polydipsia, polyuria, intolerance to heat/cold, changes in vision or energy, recent unexplained weight changes, changes to hair/skin. Haematological:
e.g. Unexplained bruising/ joint swelling, blood in stool/urine, epistaxis. Skin and Lymph:
e.g. rash, itching, limb swelling. Musculoskeletal:
e.g. Joint pain, injuries, gait/movement issues. Neurological:
e.g. cognitive changes, headache, visual or hearing changes Psychosocial:
Psychiatric (if relevant)
Kessler 10 (K10) / Patient Health Questionnaire (PHQ-9) / GAD-7 / AUDIT / Other Objective Data Collection
Children < 8 years old 3 minute toolkit from Spotting the Sick Child: https://spottingthesickchild.com/Vital Signs
HR RR SpO2 Temp BP
Weight Height BMI Cap Refill BSL
On Examination [focused or comprehensive]
Examination findings: Objective signs [INSPECT, AUSCULTATE, PALPATE, SPECIAL TESTS]
General Appearance: HEENT: CVS: Respiratory: Gastrointestinal: GU: Musculoskeletal: Endocrine: Haematological: Skin and Lymph: Neurological: Psychiatric/psychological: Review of other objective information
Previous Investigation Results:
Laboratory tests
Imaging
Dispensing history Formulating Differential Diagnoses and/or Problems
Impression:
Identify immediate RED FLAGS. Differential Diagnoses:
DDx Rule in Rule out
Other Problems:
In order of Priority
e.g. Pain, dehydration, nausea, other symptoms, social concerns/barriers, functional concerns, safety issues, knowledge/skills deficit etc Further Investigations Indicated: Final/working Diagnosis:
Plan/Management:
Diagnoses/Problem Plan Monitoring and evaluation
Discussion/ collaboration:
Medical/Nurse Practitioner
Other MDT Follow up:
Home, referrals, discharge planning, follow up.
Return advice. Other Notes:
