A medical history is a comprehensive record of a person's past and present health status, including information about medical conditions, treatments, surgeries, medications, allergies, and family medical history. It helps healthcare providers make informed decisions about diagnosis, treatment, and preventive care.
Key points:
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Chief Complaint: The patient's reason for the current visit or main health concern.
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Medical History: Include any past medical conditions, surgeries, hospitalizations, significant illnesses and diseases, and chronic conditions.
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Medication: List current medications, drugs, vitamins, supplements, and herbal remedies. List names and dosages.
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Reactions: List all known allergies, sensitivities, irritants, and adverse reactions.
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Family: List medical issues that run in the patient's family, such as heart disease, cancer, diabetes, autoimmune disorders, and hereditary concerns.
Lifestyle: List factors such as smoking, alcohol use, drug use, diet, exercise habits, occupation, and living environment.
- Systems: Review all body systems to identify any concerns. Include questions about the cardiovascular, respiratory, gastrointestinal, genitourinary, musculoskeletal, neurological, psychiatric systems, etc.