Initial patient history
Capture the story, earlier background, and the patient’s priorities.
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- Encounter & sources
- Patient: [Identifier]
Date: [Date]
History provided by: [Patient / caregiver / other]
Records reviewed: [Document, author, and date / not available]
- Presenting concern
- Reason for visit: [Patient’s own words]
Onset and course: [Timing and changes]
Daily impact: [Activities, work, or routines affected]
Patient priority: [What matters most today]
- Medical & surgical history
- Relevant conditions and procedures: [Details and dates]
Source: [Patient / caregiver / earlier record]
- Current medications
- Current list: [Details]
Source and date: [Patient / caregiver / current list]
- Allergies & reactions
- Allergies and reactions: [Details or not yet discussed]
Source and date: [Patient / caregiver / earlier record]
- Family & social history
- Relevant family history: [Details or not yet discussed]
Work, routines, living situation, and support: [Relevant context]
Source: [Patient / caregiver / record]
- Questions to carry forward
- Topics for the next visit: [Details to pick up]
Next step: [Who will clarify each item and when]
Reviewed by: [Clinician and date]