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Adult Health History SOAP Questions

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Health & Medical

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Adult Health History
Identifying data and source of the history: reliability
Name
Preferred Name
Date of birth
Age
Height
Weight
Gender
Patient primary language spoken at home
Do you require an interpreter?
Is your interpreter a family member or friend?
Race
Ethnicity/Country of origin
Marital status
Chief Complaint(choose one)
If patient has more than one complaint, discuss which one is the most troublesome for them
and
document the complaints in order of importance as determined by the patient
What has brought you in today?
So, tell me why you have come here today?
Tell me what your biggest complaint is right now?
What is bothering you the most right now?
If we could fix any of your health problems right now, what would it be?
What is giving you the most problems right now?
Present Illness
Pain assessment
Onset: When did it start?
Location: Where exactly is the pain?
Duration: How long does the pain last?
Quality: What does the pain feel like?
Quantity: How bad is the pain on a scale of 0-10?
Timing: When did this pain begin? How long does the pain last? How often does the pain
occur? How long does it last?
Setting in which it occurs? When do you experience the pain?
Factors that aggravate/alleviate: Is there anything that helps the pain? Is there anything that
makes the pain worse?

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Is there anything else that happens when the pain occurs?
Symptom assessment
Onset: When did the symptoms begin?
Begin suddenly or over time? (Ask specific date/time/day of week if appropriate)
Where were you when symptoms began?
What were you doing when symptoms began?
Does anyone else whom you have contact with have similar symptoms?
Location: Where are the symptoms?
Are the symptoms located in a specific area?
Are the symptoms vague or generalized?
Does the symptom radiate to another location?
Duration: How long do the symptoms last?
Since the symptoms began, have they become worse or about the same?
Are the symptoms constant or do they come-and-go?
If the symptoms are constant, does the severity fluctuate?
If the symptoms are intermittent, how many times a day/week/month do the
symptoms occur?
How do you feel in-between episodes of the symptom?
Characteristics: Describe the Characteristics of t.he symptoms.
How does the symptom feel or look?
Describe the sensation of the symptom: sharp, dull, aching, throbbing, nagging,
squeezing, itching, stabbing.
If applicable: Describe the appearance, color, texture, composition, and odor
Aggravating/Alleviating factors: What affects the symptoms?
What makes the symptoms worse?
Is the symptom made worse by activity? (walking, climbing stairs, eating, body
position, ect)
Are there psychological or physical factors in the environment that may be
causing them? (stress, smoke, chemicals, ect)?
What makes the symptoms better?
Do certain body positions make the symptoms better?
Related symptoms: Are other symptoms present?
Have you noticed that other symptoms have occurred at the same time? (fever,
nausea, pain)
Treatment: Describe Self-treatment before seeking care
Which methods of self-treatment have you tried?
Medications? (If yes, ask name/dosage/frequency/time of last dose)
Heat/cold applications?
Have any of these methods been effective?
Have you seen a healthcare provider for this symptom/problem?
If yes, any testing or treatment performed?
Severity/Intensity

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Adult Health History Identifying data and source of the history: reliability Name Preferred Name Date of birth Age Height Weight Gender Patient primary language spoken at home Do you require an interpreter? Is your interpreter a family member or friend? Race Ethnicity/Country of origin Marital status Chief Complaint(choose one) If patient has more than one complaint, discuss which one is the most troublesome for them and document the complaints in order of importance as determined by the patient What has brought you in today? So, tell me why you have come here today? Tell me what your biggest complaint is right now? What is bothering you the most right now? If we could fix any of your health problems right now, what would it be? What is giving you the most problems right now? Present Illness Pain assessment Onset: When did it start? Location: Where exactly is the pain? Duration: How long does the pain last? Quality: What does the pain feel like? Quantity: How bad is the pain on a scale of 0-10? Timing: When did this pain begin? How long does the pain last? How often does the pain occur? How long does it last? Setting in which it occurs? When do you experience the pain? Factors that aggravate/alleviate: Is there anything that helps the pain? Is there anything that makes the pain worse? Is there anything else that happens when the pain occurs? Symptom assessment Onset: When did the symptoms begin? Begin suddenly or over time? (Ask specific date/time/day of week if appropriat ...
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