| Communication to approach | YES (1) | NO (0) | ||||
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| Greets the patient |
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| Introduces himself/herself |
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| Ask patient how they'd like to be addressed |
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| Explains what they are going to do |
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| Treats the patient respectfully |
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| Knowledge |
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| Chief Complaint |
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| YES (1) | NO (0) | ||
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| What seems to be your problem today? | I have pain in my belly |
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| HPI |
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| YES (1) | NO (0) | ||
| Name | Leon Sheldon |
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| Age | 31 |
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| What is your Occupation? | Bank teller |
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| Abdominal pain OCD |
| YES (1) | NO (0) | |||
| When did the pain start? | This morning |
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| How did the pain start? Suddenly or gradually? | Gradually |
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| What were you doing when the pain started? | I was eating my breakfast |
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| Have you ever had abdominal pain problem before? | No |
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| Does the pain come and go? | It is a constant pain |
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| What makes the pain better? | I feel better when I'm lying still |
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| What makes the pain worse? | It is worse when I move around |
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| Do meals make the pain worse? | No |
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| Where was the pain when it started? | Around my belly button |
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| Where is the pain now? | On the lower parts of the right side |
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| What does the pain feel like? | Aching |
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| Is the pain constant, or does it come and go? | it's constant |
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| Is the pain sharp and continuous? | Yes |
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| Is the pain cramping and intermittent? | No |
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| Has the character of the pain changed since it first started? | Yes it is more severe now and the location is different |
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| How severe is the pain now, on a scale of 1 - 10, where 10 is the worst pain you ever had? | 8 |
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| Does the pain radiate anywhere, such as into the back, sides, or groin area? | No |
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| Have you noticed any palpable mass in your groin? | No |
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| Nausea and Vomiting | YES (1) | NO (0) | ||||
| Have you had any nausea? | Yes |
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| Have you had any vomiting? | Yes, once |
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| Does the vomitus contain any blood? | No |
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| Stool /Diarrhea/Bowel Habits | YES (1) | NO (0) | ||||
| How are your bowel movements? | as usual |
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| Have you noticed any change in your bowel habits? | No |
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| Any Diarrhea? | No |
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| Any Constipation? | No |
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| Is there any blood in stool? | No |
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| Any black tarry stools? | No |
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| Appetite | YES (1) | NO (0) | ||||
| Any change in your appetite? | It is much less than before |
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| Patient centered interview |
| YES (1) | NO (0) | ||
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| How do you feel about it? | I am really worried |
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| Do you have any idea what the reason behind this might be? | No |
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| What effect the illness has had on your (the patient’s) life, sleep and daily activity? | I cannot do anything |
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| What do you hope I can do for you today? | I hope you can stop the pain and tell me about the diagnosis |
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| Past Medical Hx |
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| YES (1) | NO (0) | ||
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| Alarming/Constitutional symptoms |
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| Do you have fever? | Yes, I think so |
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| Do you have night sweats? | No |
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| Do you have chills? | No |
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| Medication |
| YES (1) | NO (0) | ||
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| Are you currently on any medications? | Yes, Salbutamol as needed |
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| Why do you take this medication? | For my Asthma |
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| Allergy |
| YES (1) | NO (0) | ||
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| Do you have any allergies? | No |
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| General History |
| YES (1) | NO (0) | ||
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| Do you have history of any illnesses? | Yes |
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| Surgical History |
| YES (1) | NO (0) | ||
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| Have you ever had a surgery? | No |
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| Family Hx |
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| YES (1) | NO (0) | ||
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| Is there any other medical condition in your family that I should be aware of? | No |
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| Smoking, Alcohol and Drugs |
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| YES (1) | NO (0) | ||
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| Do you smoke? | No |
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| Do you drink alcohol? | yes |
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| How much alcohol do you usually drink? | Occasionally |
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| Have you ever used any recreational drugs? | No |
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| Personal and Social Hx |
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| YES (1) | NO (0) | ||
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| What do you do for a living? | I am a bank teller |
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| ROS |
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| YES (1) | NO (0) | ||
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| Urinary Tract |
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| Is there any pain or burning when you pee? | No |
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| Do you feel any pain in your back? | No |
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| Do you feel any pain in your groin area? | Yes |
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| Communication to Exit | YES (1) | NO (0) | ||||
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| Thanks, the patient |
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| Overall assessment | Score | |||||
| 1 | 2 | 3 | 4 | |||
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| Communication (greeting, introduction, closing) |
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| Organization of interview |
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| Questioning skills (ie open ended vs closed ending) |
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| Ability to build rapport (show empathy, doesn’t interrupt) |
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| TOTAL SCORE |
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