An adult with Back pain came to my pain management clinic. clinic consist of medical, chiropractic, physical therapy, massage etc
History of present illness (HPI):
Description of symptoms the patient is currently experiencing guide with attention to onset, frequency, duration, progression, quality, quantity, anatomic location, radiation, aggravating, alleviating, and associated factors, patient’s perception of contributing external stressors, and effect of illness on daily life.
The information is presented in chronological order and includes prior and diagnostic tests, related history, previous treatments for the problem, risk factors, family history, medications, and pertinent review of systems relevant to the differential diagnosis.
Other significant ongoing problems should be included in the HPI in a separate paragraph in detail if they relate to the chief complaint.
Health History:
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Current medications
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Prescribed
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Herbal supplements
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Over-the – counter
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Supplements
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Vitamins
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Allergies
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Drugs and environment, including manifestations
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Operations
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Hospitalizations
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Transfusions
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Type of blood product
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Number of units
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Adverse reactions
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Trauma
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Current stable problems
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Past problems unrelated to the HPI that have resolved
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Documentation that adult patients have been questioned about the following illnesses
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Usual childhood illnesses or immunizations according to CDC guidelines
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Anemia
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Asthma
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Anxiety and depression
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Bleeding disorders
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Cancer
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Diabetes
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Elevated lipids
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Emphysema
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Hepatitis
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