The chief complaint is the main reason for a patient's visit to the doctor. It is typically a brief statement that describes the patient's symptoms or concerns.
_Examples:_
- "I have a sore throat."
- "I'm having trouble breathing."
- "I'm experiencing chest pain."
Past medical history
The patient's past medical history includes a list of all the medical conditions they have ever been diagnosed with. This includes both acute and chronic conditions, as well as any surgeries or hospitalizations.
_Examples:_
- Hypertension
- Diabetes
- Asthma
- Appendicitis
- Tonsillectomy
Social history
The patient's social history includes information about their lifestyle and environment. This includes their occupation, living arrangements, marital status, and use of alcohol, tobacco, or drugs.
_Examples:_
- Smokes 1 pack of cigarettes per day
- Drinks 2 glasses of wine per week
- Works as a construction worker
- Lives in a rural area
- Married with 2 children
Family history
The patient's family history includes information about the medical conditions of their close relatives. This includes their parents, siblings, and children.
_Examples:_
- Mother has a history of breast cancer
- Father had a heart attack at age 50
- Brother has Crohn's disease
- Sister has no major medical problems
_By including this information in the chart, the physician can get a better understanding of the patient's overall health and make more informed decisions about their care._