2 pts
3 pts
4 pts
5 pts
Chronological, includes onset of problem & describes in terms of location, quality, quantity,timing, factors that aggravate or associated manifestations
include dates
Tobacco ETOH Illicit drug use Occupation Diet/Exercise Married?Children? Religious if relevant Socioeconomic
Age and health or cause of death Genogram: three generational, age of diagnosis, age of death
Current meds Dose Frequency Route CAM
Karnofsky or Lansky
Vital signs weight Height BMI
All systems
Summary of the patient with main symptoms/diagnosis
For all active problems: Therapeutic interventions Counseling/education prevention /Screening strategies Referrals Follow up
Presentation should be 20 minutes