病史采集模板001

Dr.Faust

笔者在实习过程中根据网上的经典new patient form和自身经验总结的一个比较粗陋的模板, 比较偏向于primary care first visit这种情况. 网上经典的new patient form多数都比较详尽, 而事实上病史采集的过程中用不到那么多, 实际问诊的时候更多讲究详略得当, 当然即便如此耗时也比国内多数大医院的平均接诊时间要多的多. 笔者这里仅提供一个框架, 大伙实际应用的时候尽量结合自身实际情况和经验进行适合自己的customization.

大伙如有任何疑问或者建议, 欢迎在留言区进行友好交流和讨论
另外也希望已经match的前辈们对本篇内容进行指导

Name	DOB	Contacts	PCP/referred by
	Current complaint	PMH
Allergies	7 points    Where (location w/ & w/o  radiation)    When    How    Frequency & Duration    Modifiers (triggers, lessen or  worsen to any factors)	Last relevant specialist visit    Labs & Imaging    (reason to some specific tests,  i.e. autoimmune workup, hormone, CT&MRIs)    Falls or LOC	Social history
Common allergens    Specific allergens    Medications			Sexual    Cigarettes & Alcohol    Weeds (currently legal in many  states, but have to mark down if Pt confirms daily use)    Recreational drug use
		PSH
		Major surgeries    Inpatient admission & ER  visit    Fractures
Immunizations    T-dap last 10 years       RSV    l  > 60 y.o.       VZV    l  > 50 y.o.       Flu    Pneumococcal    l  Routine  pneumococcal conjugate vaccine (PCV15 or PCV20) for all children younger than  5 years of age: Give PCV15 or PCV20 to infants as a series of 4 doses, one  dose at each of these ages: 2 months, 4 months, 6 months, and 12 through 15  months.    l  Routine  pneumococcal conjugate vaccine (PCV15 or PCV20) for all adults 65 years or  older who have never received any pneumococcal conjugate vaccine or whose  previous vaccination history is unknown:    n  If  PCV15 is used, this should be followed by a dose of PPSV23 one year later.  The minimum interval is 8 weeks and can be considered in adults with an  immunocompromising condition†, cochlear implant, or cerebrospinal fluid leak.    n  If  PCV20 is used, a dose of PPSV23 is NOT indicated.    n  See  Pneumococcal Vaccination: Summary of Who and When to Vaccinate for CDC  guidance on vaccination options for adults who have previously received a  pneumococcal conjugate vaccine.	Current Rx    Adherence & Response    Recent change in Rx    Change of pharmacy	FMH    Parents & Grandparents    Siblings    Offsprings	Preventive Screening    Mammo    l  40 to 75,       PAP    l  21 to 65 years with  cytology (Pap smear) every 3 years    l  or for 30 to 65 years  who want to lengthen the screening interval, screening with a combination of  cytology and HPV testing every 5 years.       Prostate    l  50 to 70       Colonoscopy or FIT    l  Colonoscopy  from 45 to 75    n  > 75 SE outweigh  benefit but still necessary in some case    l  Or 10 years before the  cancer onset of 1st degree relative       For patients with prominent risk  factor:    l  Sigmoidoscopy or  colonoscopy every 1 to 2 years starting at age 10 to 12 for people with FAP.    l  Individuals with AFAP  should undergo colonoscopy beginning at age 18 to 20.    n  Yearly colonoscopy  once polyps are found until a colectomy is planned.    Calcium score    l  Calcium score testing results  could help you if you're between ages 40 and 70 and at increased risk for  heart disease but don't have symptoms.       Hb A1C    DEXA    Lipids    Lung
	PE	ROS
	Vitals
	Assessments	Orders
	Others