Select a client, family member, or friend to interview for a complete health history and complete a physical examination. Only use the individual’s initials when referring to the client.
Subjective (History): 27 points
I. Identifying Data
II. Chief Complaint (CC)
III. History of Present Illness (HPI)
IV. Past Medical History (PMH)
A. Hospitalizations
B. Surgeries
C. Medications
D. Allergies
V. Family History
VI. Social History
VII. Review of Systems
A. General
B. Skin
C. HEENT
D. Neck
E. Cardiovascular
F. Respiratory
G. Gastrointestinal
H. Genitourinary
I. Musculoskeletal
J. Neurological
K. Mental Health
Objective (Physical) 27 points
I. Constitutional: Vital Signs, General appearance, initial impression
II. Skin
III. Eyes
IV. Ears, Nose, Throat/Neck
V. Cardiovascular
VI. Pulmonary
VII. Abdomen
VIII. Musculoskeletal
IX. Neurological
