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.
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