I created this form for history taking in the Urgent care where I work. It has been successfully utilized there for last 5 months. Also it can be used in other settings. I understand that it should be improved for perfection. I shall apreciate your suggestions.

1. Date:
Physician/assistant’s name:
Procedures: EKG Flu Rapid Strep Xray____________ HCG U/A PPD Cerumen removal MEDS
Ketorolac Zofran Other Inj. Vaccines:Flu Tdap
Screening: mammogram colonoscopy CT chest Pap smear Eye exam Feet exam ABI
Routine tests: CBC/CMP/TSH/Vit-D/Lipid/HbA1C
By: Ishtiaque Khan
Name: Last:______________First_____________DOB: / / /
C/C:___________________________ Allergy:___________________ reaction_____________________
Pharmacy:__________________address___________________________________________________
Location Medication
Context
Continued/ Intermittent
Radiation
Quality OCP/Vitamins/
Pain killer
Improving factor Family F-alive/deceased-
DM/HTN/high
cholesterol/Heart
disease/cancer
Worsening factor M-alive/deceased-
DM/HTN/high
cholesterol/Heart
disease/cancer
Intensity Social Hx: cig/ alcohol/
marijuana/cocaine/others
Association Sick contact
Female Hx LMP:
Any abnormalities
Nausea/Vomit Sexual Hx No of partner in 6 m:
Fever STD:
Urinary complaints Injury
Bowel complaints Insect bite:
PMH DM/HTN/Hyperlipidemi
a/CAD/CVA/Thyroid
Recent Travel
Asthma/COPD
intubation
PEF
Hospitalization Physical exam
positive findings
Notes:_______________________________________________________________________
____________________________________________________________________________