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Instant Medical History Sample Report

(These history items can be imputed to the appropriate sections of the patients file in Medinotes)

 

Chief Complaint

Mark Smith is a 30 year old male. His reason for visit is "allergies".

 Past, Family, and Social History

He denied: Thyroid disease. Diabetes mellitus. Gout. Arthritis. Asthma, hay fever, eczema. Cataracts, color blindness, or glaucoma. Deafness (under age 50). Bleeding tendency, hemophilia, leukemia. Obesity. Hepatitis. Kidney stones. Cancer. Migraine headaches. Epilepsy. Mental health problems, learning disabilities, suicide. Alcoholism. Tuberculosis. White patches of skin, psoriasis, early graying of hair before age 30, or baldness of hair. High blood fats. Eczema. Loss of pigment of the skin.

Past Medical History

History of: Previously had a problem with asthma. Asthma was a problem 1-5 years ago. Emphysema developed one to four years ago. High blood pressure. Psoriasis developed within the past year.

He denied: Kidney disease. Degenerative disorders. Autoimmune disorders. Consultation with an allergist. Pneumonia two or more times. Bronchiectasis. Blood clot in the lungs. Cirrhosis. Poor circulation. Gastrointestinal disorder. Prostate gland trouble. Infectious diseases. Mental or emotional problems.

Surgical History

He denied: Surgery. Skin moles removed by a doctor.

Family History

He denied: Emphysema (distant family). Asthma. Cirrhosis (distant family). Alzheimer's or dementia.

Father

History of: Emphysema.

Mother

History of: Emphysema.

Brother

History of: Cirrhosis.

Social History

History of: Living in a mobile home. Home is less than 1 year old. Living in present home 1 to 5 years.

He denied: Working outside the home.

Tobacco Use

He reported: Never used tobacco.

Environmental Hazards

He denied: Exposed to someone who smokes indoors at work. Someone smokes indoors at home.

Medication History

History of: Non-prescription antihistamines somewhat effective for allergies. He denied: Inhaler use.

Ongoing Medications

He denied: Neosynephrine nasal spray.

Over-the-counter Medications

He denied: Non-prescription antihistamines.

Allergy History

            He denied: Allergic to chemicals. Nasal allergies like stuffiness, sinus drainage, runny nose, sneezing, or nasal polyps.

Medication Allergies

       History of: Slight effect from a drug on allergy symptoms.

       He denied: Allergic to medication prescribed and X-ray material.

Aeroallergen Triggers

      History of: Allergic reaction onset to mold in < 15 min and plants in minutes up to 3 hours.

      Drug allergy to molds.

      Allergy symptoms worse in fall.

      Allergic symptoms related to damp basements, grass, and mowing grass.

      Allergic reaction severity to mold is mild and plants is moderate.

      Seasonal allergy complaints.

          Allergic to pollen. House dust slight effect on allergy symptoms. Grass pollen slight effect on allergy symptoms.

        Flowers slight effect on allergy symptoms. Tree pollen slight effect on allergy symptoms. Slight effect from a cosmetics

         or perfumes on allergy symptoms. Tobacco smoke slight effect on allergy symptoms. Polluted air slight effect on

        allergy symptoms.

     He denied: Allergy symptoms improve on vacation. Allergic symptoms related to raking leaves, trees, hay,

      compost/mulch, and weeds. Allergic to barns, silos, circuses, and tobacco smoke. Mold and mildew problems

     in home.

Living Quarters Environment

History of: Commonly used rooms have wall to wall carpet with pad, wall to wall carpet without pad, rug with pad, rug without pad, throw rug, vinyl/linoleum flooring, hardwood flooring, some other type of flooring, plants, and mold growth. Foam insulation in home. Basement has stuffed toys. Basement has a humidifier. Basement has a window air conditioner. He denied: Allergy symptoms worse at home. Allergic symptoms from exposure to mold in home, exposure to air conditioner in home, exposure to air from humidifier, exposure to stuffed toys in home, and exposure to plants in home. Moisture problems in home. Carpet or rugs in home. Indoor plants. Frequent pesticide treatment at home. Recent home construction. Home has central air conditioner. Home has forced air heat.

Bedroom Environment

History of: Bedroom has air filtration system and HEPA filter. Bedroom has dehumidifier. Mattress has no occlusive cover. Mattress is filled with feathers. Pillow is filled with feathers.

He denied: Keeping dirty clothes in bedroom. Mattress is over 1 year old. Pillow is over 1 year old.

Workplace Environment

He denied: Allergy symptoms worse at work.

Food Reactions

     He denied: Allergic to foods.

Animal Exposures

    He denied: Allergic to animals. Reaction to insect bite. Not allergic to feathers.

Physical Triggers

        History of: Exertion slight effect on allergy symptoms. Change in temperature

slight effect on allergy symptoms. Damp air slight effect on allergy symptoms.

He denied: Allergic symptoms after exercise.

Contact Allergies

He denied: Allergic to soaps, cosmetics, or personal hygiene products, hair colorants, tape, iodine, and latex.

Non-specific Triggers

History of: Allergy symptoms are worse when at home and worse outdoors. He denied: Allergy symptoms worse at certain times of day. Allergic symptoms from exposure to carpets in home. Allergic to dust and environmental changes (weather, temperature, sunlight, pollutants).

Review of Systems

Eye

He denied: Eye allergies like irritation, itching, or swollen eyelids.

Ear, Nose, and Throat

He denied: Sore throat. Ear symptoms include ringing, plugged, dizziness, or earache. Lip swelling. Tongue swelling. Mouth ulcers. Scratchy throat. Throat swelling. Throat tightness. Palate burning or itching.

Dental Health

He denied: Gums swollen.

Respiratory

He reported: Tuberculosis was a problem 1-5 years ago. Previously had a problem with tuberculosis.

He denied: Chest allergies like wheezing, tightness, shortness of breath, cough, or sputum (phlegm). Chronic cough.

Gastrointestinal

He denied: Intestinal allergies of nausea, indigestion, loose stools, or gas.

 Skin

He denied: Skin allergies like itching, red patches, blisters, eczema.

Return

 

 

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