Good Morning/Good Afternoon/Good Night
My name is (name) and I’m a medical student at the Alabama College of Medicine.
What is your name?
What is your age?
What would you like me to call you/How would you like to be addressed?
How can I help you today?/What brings you in today?
Is there anything else we need to discuss or take care of while you’re here?
Work excuse
Refill your medication
So, we need to discuss the _____, get you a work excuse, and refill your medication. Is that correct?)
(Example: Entonces, necesitamos discutir el problema, consiguir su excusa de trabajo, y rellenar la receta para su medicamento para _____?. ¿Es eso correcto?
So, tell me more about why you came in today.
How is this affecting your daily life?
How are you doing with this? How does this make you feel? How has this affected you emotionally?
I can understand your feeling this way. This has been a difficult time for you. I want to help you get to the bottom of this and see what we can do.
What made you decide to come in today?
How is this affecting your job?
What has this issue been like for your family?
What do you think might be causing this?
What else is going on in your life?
Anything else?
Thank you for coming in today. We are going to work together to solve your problem. I’m going to ask you more questions specifically about your case.
ONSET:
When did it start?
What were you doing when it started?
PALLIATIVE:
What makes the pain better?
Anything else?
PROVOCATIVE
What makes the pain worse?
Anything else?
QUALITY
Where does it hurt?
Please describe your pain.
Anything else?
RADIATION
Does the pain radiate to other parts of the body?
SCALE
On a scale from 1-10, supposing the number 1 is for the mildest pain you’ve ever felt, and the number 10 is the worst pain you’ve ever felt, how would you rate this pain?
Has the pain ever been lower than # ? What were you doing during that moment?
Has the pain ever been lower than # ? What were you doing during that moment?
TIME
Has the pain been constant or intermittent since it started?
Have you had this problem before?
ASSOCIATED SYMPTOMS
SUMMARIZING
Just to summarize, this is why you came in today.....
Is this correct? Is there anything else you would like to add to this?
Thank you very much.
TRANSITIONING
So, I want to solve this issue for you.
But before I take this information to my preceptor, can I ask you some questions about your past medical history?
Thank you.
PAST MEDICAL HISTORY
How is your general health?
What illness or medical problems have you had?
What other medical problems have you had?
What medications do you take currently?
How many times a day do you take the medication?
What is the dosage?
What other medications do you take?
What natural or herbal supplements do you take?
How many times a day do you take the medication?
What is the dosage?
What other medications do you take?
Do you have any allergies?
What is the reaction like?
What surgeries have you had done? When?
Have you ever been hospitalized? When? Why?
Have you had any ER visits? When? Why?
FAMILY HISTORY
How is your family?
Any illness in your family?
Anyone in your family have (disease)?
Are your parents alive?
YES
How old are they?
How’s the health of your mother/father?
What other medical problems have they had?
NO
When did they die?
What did they die from?
Did they have any illness or medical problems?
Do you have any siblings?
How old are they?
How’s the health of your siblings?
What other medical problems have they had?
Do you have any children?
How many?
Male or Female?
How’s the health of your son/daughter?
What other medical problems have they had?
SOCIAL HISTORY
Now I will ask more personal questions. I ask all of my patients these questions. Our conversation is completely confidential.
Who do you live with?
What is your occupation?
Do you smoke tobacco?
How many packs a day?
For how many years?
Do you drink alcohol or beer? Which type?
How much alcohol or beer do you drink? What size?
Have you used any other drugs? Which?
How is your diet?
Do you exercise?
REVIEW of SYSTEMS
Now I’m going to ask you a series of questions regarding your health. Say just yes or no.
In the last (time frame), have you experienced…?
Do you have any questions?
Now we are going to do the physical exam.