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ID

43122

Description

Form from HIS OpenVistA

Keywords

EHR

Routine documentation

Medical History Taking

Versions (3)

2/21/12 2/21/12 -
5/21/14 5/21/14 - Martin Dugas
9/20/21 9/20/21 -

Uploaded on

September 20, 2021

DOI

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License

Creative Commons BY-NC 3.0 Legacy

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HIS Review of Systems

English 2

German English

Details

HIS

1 forms

StudyEvent: HIS
1. HIS

GENERAL

Positive for

Negative for

NARRATIVE

Denies change in appetite or weight. Denies fever, chills, dizziness

Yes

Appetite change

Yes

Weight increased, Wt gain

Yes

Weight Loss, Decreased weight

Yes

Fever, pyrexia, Body temperature increased, Temperature elevation

Yes

Chills

Yes

dizzy

Yes

Additional comments

EYE

eye

Denies change in vision

Yes

Denies diplopia, itchy/dry eyes, photophobia or eye pain

Yes

Blurry vision, Hazy vision, Cloudy vision

Yes

Diplopia (B/L/R)

Itchy Eyes (B/L/R)

Dry eyes (B/L/R)

Change in Vision (B/L/R)

Loss of Vision (B/L/R)

Eyeglasses, Spectacles

Colour blindness

Light Sensitivity

Pain

EAR

ear, ear structure

Denies earache,deafness,tinnitus,vertigo,or discharge

Yes

ear ache, ear pain, otalgia

Deafness

Tinnitus, Ear noises, Ear ringing

Vertigo, Spinning Sensation

Discharge (Dx)

NOSE

Nose, nasal structure

Denies rhinorrhea, epistaxis, sneezing, or sinus pain/tenderness

Yes

Rhinorrhoea, Nasal catarrh, Nasal discharge, Nose dripping, Nose running, runny nose

Nasal Bleeding, Nose Bleed, Hemorrhage from nose

Sneezing

Nasal sinus tenderness

MOUTH

Mouth region, Oral region

Denies toothache, mouth sores, dysphagia, odynophagia

Yes

Tooth pain, Odontalgia, Dentalgia

Deglutition Disorders

Swallowing painful, Pain on swallowing

Mouth ulceration, Oral Ulcer, Oral sore, Ulcer of mouth

RESPIRATORY

Respiratory System

Denies chest pain, shortness of breath, or cough

Yes

Dyspnoea, Shortness of Breath (SOB), Breathlessness

Dyspnea on exertion (DOE), Dyspnoea on effort, Exertional dyspnea, Breathlessness on exertion

Orthopnoea, Breathlessness lying flat

Coughing

Sputum, Expectoration

Haemoptysis, Coughing blood, Blood streaked sputum

Pain

CARDIOVASCULAR

Cardiovascular system

Denies chest pain or palpitations

Yes

Chest pain

Location

radiation

TYPE

Disease severity

Pain exacerbating factors

Symptom relieving factors

Timing

Palpitations

Orthopnoea, Breathlessness lying flat

Paroxysmal nocturnal dyspnea, Dyspnoea paroxysmal nocturnal

Leg oedema, Edema of leg

GASTROINTESTINAL

Gastrointestinal system, Digestive system

Denies heartburn, abdominal pain, nausea, vomiting, blood in stool,diarrhea, or constipation.

Yes

Heartburn, Pyrosis, Burning reflux

Abdominal Pain

Nausea

Emesis

Incontinence

Haematemesis

Diarrhea

Constipation

bright red blood in stool

Blood in Stool

Melaena

GENITOURINARY

Genitourinary system, Urogenital system

Denies dysuria, hematuria

Yes

Dysuria, Micturition painful, Painful urination

haematuria, Blood in urine

Impotence, Erectile dysfunction (ED), Erection failure, Male erectile dysfunction

Bleeding of vagina, Haemorrhage vaginal, Per vaginal (PV) bleeding

Vaginal discharge, Fluor vaginalis

Dyspareunia, Pain on intercourse

MUSCULOSKELETAL

Musculoskeletal System, Musculo-skeletal system

Denies muscle or joint pain or swelling.

Yes

Muscle pain, Myalgia, Muscle ache, Muscular pain

Back pain, Backache, Dorsalgia, Dorsal pain

Stiffness

Joint pain, Arthralgia, Articular pain, Joint ache, Pain in joint

Joint swelling, Swollen joint

NEUROLOGIC

Neurologic system, Nervous system, Nervous system structure

Denies headache, dizziness, weakness or paresthesias

Yes

dizzy

Cephalgia

weakness

Paraesthesia, Paresthesia

PAIN

Pain

Pain severity (1-10)

Location

radiation

EXACERBATING FACTORS

RELIEVING FACTORS

GERIATRIC

geriatric

Falls, falling

Yes

Incontinence

Yes

Memory loss, Loss of memory

Yes

Wandering, Wandering around

Yes

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HIS Review of Systems

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