ADULT HISTORY SCORING FORM

First Name:
Last Name:
Student ID:

Chief Complaint
elicit chief complaint	select answerYesNo

Past Medical History
How do you rate your health in general?	select answerYesNo
Childhood illnesses?	select answerYesNo
Adult/current illnesses?	select answerYesNo
Any past accidents or injuries?	select answerYesNo
Any surgeries?	select answerYesNo
Any Hospitalizations? (include pregnancy, when?, how long?)	select answerYesNo
Current medications (include prescription and nonprescription, why do you take them, dosing schedule, how long, side effects)	select answerYesNo
Any allergies? (what sort of reaction)	select answerYesNo
Immunizations up to date?	select answerYesNo
OB hx: Number of pregnancies and live births? Type of deliveries?	select answerYesNo
Sexually active, how many partners	select answerYesNo
Gender of partners?	select answerYesNo
Any problems with sexual performance (desire, dryness, pain etc)	select answerYesNo
Any hx of sexually transmitted diseases or any abnormal PAP smear in the past?	select answerYesNo
Any concern about contracting an STD or becoming pregnant?	select answerYesNo
Psych hx: Have you ever been diagnosed with a psychiatric illness like depression, anxiety or bipolar? (if yes, follow up)	select answerYesNo
Have you ever seen a psychologist or counselor, or felt very down or extremely anxious? (if yes, follow up)	select answerYesNo
Do your see any other doctors?	select answerYesNo
Do you regularly see a dentist, ophthalmologist, gynecologist?	select answerYesNo
Are you up to date on mammograms, pap smears, lipid profile, PE?	select answerYesNo

Social History
Who do you live with?	select answerYesNo
Is your home in a safe environment?	select answerYesNo
Who is involved in your life (social support/ family)?	select answerYesNo
What do you do for a living? Spouse?	select answerYesNo
Any financial concerns, health insurance?	select answerYesNo
Any potential environmental exposures or hazards (in home or occupation)?	select answerYesNo
Safety? (seatbelt, CO detectors, Smoke detectors, guns)	select answerYesNo
Domestic violence?	select answerYesNo
Support groups, what do you do for fun?	select answerYesNo
Describe your daily routine?	select answerYesNo
Diet?	select answerYesNo
Exercise? (How much, how often?)	select answerYesNo
Sleep? (How much, is it sufficient?)	select answerYesNo
Any religious beliefs that are important to you/ how do you cope with stress?	select answerYesNo
How much do you drink? How often and for how long?	select answerYesNo
Do you/have you ever smoked? How much and for how long?	select answerYesNo
Do you/ have you ever used recreational drugs? How much, how often and for how long?	select answerYesNo

Family History
Do any diseases run in your family? (MI, stroke, diabetes, COPD, psychiatric diseases, dementia, cancer, HTN, hyperlipidemia, bone dis.)	select answerYesNo
Are your parents alive? How old, and if not what did they die of?	select answerYesNo
Did your parents suffer from any diseases?	select answerYesNo
Are your siblings alive? How old and do they have any health problems?	select answerYesNo
Are your children healthy?	select answerYesNo
Are your grandparents alive? What did they die from?	select answerYesNo
How old are you?	select answerYesNo

MIRS
Opening	select answer12345
Elicits Spectrum of Concerns	select answer12345
Negotiates Priorities and Sets Agenda	select answer12345
Eliciting the Narrative Thread or the "Patient's Story"	select answer12345
Timeline	select answer12345
Organization	select answer12345
Transitional Statements	select answer12345
Pacing of Interview	select answer12345
Types of Questions	select answer12345
Summarizing	select answer12345
Duplication	select answer12345
Lack of Jargon	select answer12345
Verification of Patient Information	select answer12345
Verbal Facilitation Skills	select answer12345
Non-Verbal Facilitation Skills	select answer12345
Empathy and Acknowledging Patient Cues	select answer12345
Support Systems	select answer12345
Encouragement of Questions	select answer12345
Closure	select answer12345