Part I: Comprehensive Health History
Subjective Data
Chief Complaint (CC):
History of Present Illness (HPI):
Past Medical History (PMH):
Surgical History (PSH):
Medications:
Allergies:
Preventive Health:
Social History (social determinants of health):
Review of Systems (ROS)
General:
Skin:
HEENT:
Cardiac:
Respiratory:
Gastrointestinal (GI):
Genitourinary (GU):
Musculoskeletal (MSK):
Neurologic:
Psychiatric:
Endocrine:
Hematologic/Lymphatic/Immune:
Part II: Reflection (1 page minimum)
Part II, Section 1: Additional Questions
Identify 3–5 questions you would ask the patient to further strengthen your assessment. Make sure at least one question relates to social determinants of health.
For each question: • State the question • Explain why it is clinically important • Describe how the answer could influence your assessment
Part II, Section 2: Professional Growth
Identify one area where you would improve your interviewing skills based on this case. Briefly explain how you plan to strengthen that area.
References
List 3–5 peer-reviewed references, less than 5 Years Old. Cite all sources in APA format.