02 Jun NURS 6512: Comprehensive Health History Reference Sheet

Chief Complaint (CC)

• State the patient’s main reason for visit — concise and focused. • Use the patient’s own words in quotes (1–2 words or one short sentence). • Example: “Sore throat for two days.” or “Shortness of breath.”

History of Present Illness (HPI) – OLDCARTS + Pertinent History

• Use OLDCARTS to gather data, then synthesize into a cohesive paragraph written in complete sentences. • Avoid bullet points. Tell the story of the symptom(s) using the data you collected. • O – Onset: When did it start? • L – Location: Where is it? Does it radiate? • D – Duration: Constant or intermittent? • C – Character: Describe the quality (sharp, dull, throbbing). • A – Aggravating factors: What makes it worse? • R – Relieving factors: What makes it better? • T – Timing: Pattern, frequency, time of day. • S – Severity: 0–10 pain scale or functional impact. • Include associated symptoms and pertinent negatives (important symptoms the patient denies). • Incorporate pertinent history such as recent illness, exposures, travel, medications tried, previous episodes, or related chronic conditions. • Example: The HPI should read as a full paragraph that flows logically and reflects critical thinking — not as a list of OLDCARTS items.

Past Medical History (PMH)

• Chronic illnesses (HTN, DM, asthma, etc.) • Childhood illnesses (if relevant) • Hospitalizations and psychiatric history

Surgical History (PSH)

• List all surgeries/procedures with year, indication, and complications

Medications

• List all: prescription, OTC, herbal, and supplements • Include name, dose, route, frequency, indication • Note adherence and side effects

Allergies

• Drug, food, environmental — include reaction type (rash, anaphylaxis, etc.) • Document tolerated alternatives if known

Preventive Health

• Immunizations: Flu, COVID-19, Tdap, shingles, pneumococcal • Screenings: Pap, mammogram, colonoscopy, lipid, glucose, DEXA • Risk factors: Diet, exercise, safety, sexual health, sleep, stress, dental, vision

Social History

• Tobacco: Type, amount, duration, quit attempts • Alcohol: Type, frequency, quantity (CAGE if indicated) • Substance use: Illicit or prescription misuse • Occupation: Exposures, stress, satisfaction • Living situation & support system • Safety: IPV, firearms, seatbelt use • Social Determinants of Health (SDOH): Housing, food, transport, access, finances

Review of Systems (ROS)

These are subjective symptoms that the patient reports. No objective exam findings should be included here.

• General: Fever, chills, weight change, fatigue • Skin: Rashes, lesions, itching • HEENT: Vision, hearing, congestion, sore throat • Cardiac: Chest pain, palpitations, edema • Respiratory: Cough, SOB, wheezing • GI: N/V/D, constipation, pain, appetite • GU: Dysuria, frequency, hematuria • MSK: Joint pain, stiffness, weakness • Neuro: Headache, dizziness, numbness, seizures • Psych: Mood, anxiety, sleep • Endo: Heat/cold intolerance, polyuria/polydipsia • Heme: Easy bruising/bleeding