Shadow Health Tina Jones HEENT Subjective Data Collection
28 of 29 (96.6%)
Category
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Experts chose these topics as crucial parts of a comprehensive interview with the patient.
Patient Data
Not Scored
Using a mix of open and closed questions can yield more patient data. The following details are factual information about the patient’s case.
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Chief Complaint
Finding:
The patient has a specific chief complaint.
Finding:
The patient reports having a sore throat.
Pro Tip: A patient’s chief complaint indicates any illnesses or concerns they are presenting. Asking about it allows the patient to express any concerns or symptoms they may have.
Example Question: Is your throat sore?
Finding:
The patient reports having an itchy throat.
Pro Tip: A patient’s chief complaint indicates any illnesses or concerns they are presenting. Asking about it allows the patient to express any concerns or symptoms they may have.
Example Question: Is your throat itchy?
Finding:
The patient reports having itchy eyes.
Pro Tip: A patient’s chief complaint indicates any illnesses or concerns they are presenting. Asking about it allows the patient to express any concerns or symptoms they may have.
Example Question: Are your eyes itchy?
Finding:
The patient reports having a runny nose.
Pro Tip: A patient’s chief complaint indicates any illnesses or concerns they are presenting. Asking about it allows the patient to express any concerns or symptoms they may have.
Example Question: Do you have a runny nose?
History of Present Illness
Finding:
The patient was asked about when their symptoms began.
Finding:
The patient reports that their sore throat started one week ago.
Pro Tip: Inquiring about the duration of the patient’s health issues provides information relevant to the history of their present illness. Details of their current complaint can help with follow-up questions.
Example Question: How long has your throat been sore?
Finding:
The patient reports that their runny nose also began one week ago.
Pro Tip: Inquiring about the duration of the patient’s health issues provides information relevant to the history of their present illness. Details of their current complaint can help with follow-up questions.
Example Question: When did your nose start running?
Finding:
The patient reports that their itchy eyes started one week ago.
Pro Tip: Inquiring about the duration of the patient’s health issues provides information relevant to the history of their present illness. Details of their current complaint can help with follow-up questions.
Example Question: When did your eyes start itching?
Finding:
The patient was asked about factors that might worsen throat symptoms.
Finding:
The patient reports that their throat pain is constant.
Pro Tip: Inquiring about the duration of the patient’s current health issues provides information relevant to the history of their present illness. Details of their current complaint can help with follow-up questions.
Example Question: Is the throat pain constant?
Finding:
The patient reports that their throat pain is worse in the morning.
Pro Tip: Inquiring about the duration of the patient’s current health issues provides information relevant to the history of their present illness. Details of their current complaint can help with follow-up questions.
Example Question: When does your sore throat feel the worst?
Finding:
The patient reports experiencing some soreness when swallowing.
Pro Tip: Inquiring about the duration of the patient’s current health issues provides information relevant to the history of their present illness. Details of their current complaint can help with follow-up questions.
Example Question: Does it hurt when you swallow?
Finding:
The patient was asked to rate the severity of their throat discomfort.
Finding:
The patient reports their sore throat discomfort as mild to moderate.
Pro Tip: Inquiring about the duration of the patient’s current health issues provides information relevant to the history of their present illness. Details of their current complaint can help with follow-up questions.
Example Question: Can you rate your sore throat on a scale of 0 to 10?
Finding:
The patient was asked about the frequency and duration of their runny nose.
Finding:
The patient reports that their runny nose is constant.
Pro Tip: Inquiring about the duration of the patient’s current health issues provides information relevant to the history of their present illness. Details of their current complaint can help with follow-up questions.
Example Question: How often does your nose run?
Finding:
The patient was asked about nasal symptoms.
Finding:
The patient denies having an itchy nose.
Pro Tip: Inquiring about the duration of the patient’s current health issues provides information relevant to the history of their present illness. Details of their current complaint can help with follow-up questions.
Example Question: Does your nose itch?
Finding:
The patient denies having sinus pain.
Pro Tip: Inquiring about the duration of the patient’s current health issues provides information relevant to the history of their present illness. Details of their current complaint can help with follow-up questions.
Example Question: Do you feel any sinus pain?
Finding:
The patient denies having sinus pressure.
Pro Tip: Inquiring about the duration of the patient’s current health issues provides information relevant to the history of their present illness. Details of their current complaint can help with follow-up questions.
Example Question: Do you feel any sinus pressure?
Finding:
The patient denies having sneezing.
Pro Tip: Inquiring about the duration of the patient’s current health issues provides information relevant to the history of their present illness. Details of their current complaint can help with follow-up questions.
Example Question: Have you been sneezing?
Finding:
The patient was asked about the character of nasal discharge.
Finding:
The patient reports having clear nasal discharge.
Pro Tip: Inquiring about the duration of the patient’s current health issues provides information relevant to the history of their present illness. Details of their current complaint can help with follow-up questions.
Example Question: What color is your mucus?
Finding:
The patient reports having thin nasal discharge.
Pro Tip: Inquiring about the duration of the patient’s current health issues provides information relevant to the history of their present illness. Details of their current complaint can help with follow-up questions.
Example Question: Is the mucus thick?
Finding:
The patient denies having pus in their nasal discharge.
Pro Tip: Inquiring about the duration of the patient’s current health issues provides information relevant to the history of their present illness. Details of their current complaint can help with follow-up questions.
Example Question: Does your mucus have pus in it?
Finding:
The patient was asked about eye symptoms.
Finding:
The patient reports constant itching of their eyes.
Pro Tip: Inquiring about the duration of the patient’s current health issues provides information relevant to the history of their present illness. Details of their current complaint can help with follow-up questions.
Example Question: Do your eyes constantly itch?
Finding:
The patient reports redness in their eyes.
Pro Tip: Inquiring about the duration of their present illness. Details of their current complaint can help with follow-up questions.
Example Question: Are your eyes red?
Finding:
The patient was asked about related respiratory symptoms.
Finding:
The patient reports that their breathing is not affected.
Pro Tip: Inquiring about the duration of the patient’s current health issues provides information relevant to the history of their present illness. Details of their current complaint can help with follow-up questions.
Example Question: Have you had any changes in your breathing?
Finding:
The patient denies having a cough.
Pro Tip: Inquiring about the duration of the patient’s current health issues provides information relevant to the history of their present illness. Details of their current complaint can help with follow-up questions.
Example Question:
Do you have a cough?
Finding:
The patient denies having chest tightness.
Pro Tip: Inquiring about the duration of the patient’s current health issues provides information relevant to the history of their present illness. Details of their current complaint can help with follow-up questions.
Example Question: Does your chest feel tight?
Finding:
The patient was asked about related asthma symptoms.
Finding:
The patient denies recent wheezing.
Pro Tip: Inquiring about the duration of the patient’s current health issues provides information relevant to the history of their present illness. Details of their current complaint can help with follow-up questions.
Example Question: Have you been wheezing?
Finding:
The patient denies an increase in recent asthma symptoms.
Pro Tip: Inquiring about the duration of the patient’s current health issues provides information relevant to the history of their present illness. Details of their current complaint can help with follow-up questions.
Example Question: Has your asthma been worse lately?
Finding:
The patient was asked about the perceived cause of their symptoms.
Finding:
The patient reports that their symptoms are similar to allergies.
Pro Tip: Inquiring about the duration of the patient’s current health issues provides information relevant to the history of their present illness. Details of their current complaint can help with follow-up questions.
Example Question: Do you know what’s causing your symptoms?
Finding:
The patient reports that their symptoms don’t seem like a common cold.
Pro Tip: Inquiring about the duration of the patient’s current health issues provides information relevant to the history of their present illness. Details of their current complaint can help with follow-up questions.
Example Question: Do you think you have a cold?
Finding:
The patient reports that their symptoms are similar to their sister’s hay fever symptoms.
Pro Tip: Inquiring about the duration of the patient’s current health issues provides information relevant to the history of their present illness. Details of their current complaint can help with follow-up questions.
Example Question: Do you think you are having an allergic reaction?
Finding:
The patient was asked about any measures taken to alleviate nose and eye symptoms.
Finding:
The patient denies using any treatment for itchy eyes.
Pro Tip: Inquiring about the duration of the patient’s current health issues provides information relevant to the history of their present illness. Details of their current complaint can help with follow-up questions.
Example Question: Have you treated your eyes with anything?
Finding:
The patient denies using any treatment for nasal symptoms.
Pro Tip: Inquiring about the duration of the patient’s current health issues provides information relevant to the history of their present illness. Details of their current complaint can help with follow-up questions.
Example Question: Have you done anything for your runny nose?
Finding:
The patient denies taking antihistamines.
Pro Tip: Inquiring about the duration of the patient’s current health issues provides information relevant to the history of their present illness. Details of their current complaint can help with follow-up questions.
Example Question: Have you taken any antihistamines?
Finding:
The patient denies taking decongestants.
Pro Tip: Inquiring about the duration of the patient’s current health issues provides information relevant to the history of their present illness. Details of their current complaint can help with follow-up questions.
Example Question: Have you taken any decongestants?
Finding:
The patient was asked about measures to relieve throat symptoms.
Finding:
The patient reports using lozenges as treatment.
Pro Tip: Inquiring about the duration of the patient’s current health issues provides information relevant to the history of their present illness. Details of their current complaint can help with follow-up questions.
Example Question: Have you taken anything for your sore throat?
Finding:
The patient reports that lozenges reduce their symptoms.
Pro Tip: Inquiring about the duration of the patient’s current health issues provides information relevant to the history of their present illness. Details of their current complaint can help with follow-up questions.
Example Question: Do the lozenges help?
Finding:
The patient reports ingesting lozenges every few hours.
Pro Tip: Inquiring about the duration of the patient’s current health issues provides information relevant to the history of their present illness. Details of their current complaint can help with follow-up questions.
Example Question: How often do you have a lozenge?
Finding:
The patient reports that drinking water reduces their symptoms.
Pro Tip: Inquiring about the duration of the patient’s current health issues provides information relevant to the history of their present illness. Details of their current complaint can help with follow-up questions.
Example Question: Does drinking water help?
Home Medications
Finding:
Confirmed home medications.
Finding:
The patient reports not starting any new medications.
Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.
Example Question: Have you started taking any new medications?
Finding:
Followed up on inhaler use.
Finding:
The patient reports using an inhaler to treat asthma symptoms.
Shadow Health Tina Jones HEENT Subjective Data Collection
: 28 of 29 (96.6%)
Hover over the Patient Data items below to reveal important information, including Pro Tips and Example Questions.
-
Found:
Indicates an item that you found.
-
Available:
Indicates an item that is available to be found.
Category
Scored Items
Experts selected these topics as essential components of a strong, thorough interview with this patient.
Patient Data
Not Scored
A combination of open and closed questions will yield better patient data. The following details are facts of the patient’s case.
Chief Complaint
Finding:
Established chief complaint
Finding:
Reports sore throat
(Found)
Pro Tip: A patient’s chief complaint establishes any illnesses or concerns they are presenting. Asking about the chief complaint will allow the patient to voice any concerns or symptoms the patient may have.Example Question:
Is your throat sore?
Finding:
Reports itchy throat
(Found)
Pro Tip: A patient’s chief complaint establishes any illnesses or concerns they are presenting. Asking about the chief complaint will allow the patient to voice any concerns or symptoms the patient may have.Example Question:
Is your throat itchy?
Finding:
Reports itchy eyes
(Found)
Pro Tip: A patient’s chief complaint establishes any illnesses or concerns they are presenting. Asking about the chief complaint will allow the patient to voice any concerns or symptoms the patient may have.Example Question:
Are your eyes itchy?
Finding:
Reports runny nose
(Found)
Pro Tip: A patient’s chief complaint establishes any illnesses or concerns they are presenting. Asking about the chief complaint will allow the patient to voice any concerns or symptoms the patient may have.Example Question:
Do you have a runny nose?
History of Present Illness
Finding:
Asked about onset of symptoms
Finding:
Reports sore throat began 1 week ago
(Found)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.Example Question:
How long has your throat been sore?
Finding:
Reports runny nose began 1 week ago
(Found)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.Example Question:
When did your nose start running?
Finding:
Reports itchy eyes began 1 week ago
(Found)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.Example Question:
When did your eyes start itching?
Finding:
Asked about aggravating factors for throat symptoms
Finding:
Reports throat pain is constant
(Found)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.Example Question:
Is the throat pain constant?
Finding:
Reports throat pain is worse in the morning
(Found)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.Example Question:
When does your sore throat feel the worst?
Finding:
Reports some soreness with swallowing
(Available)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.Example Question:
Does it hurt when you swallow?
Finding:
Asked severity of throat discomfort
Finding:
Reports sore throat discomfort as mild to moderate
(Found)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.Example Question:
Can you rate your sore throat on a scale of 0 to 10?
Finding:
Asked about frequency and duration of runny nose
Finding:
Reports runny nose is constant
(Found)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.Example Question:
How often does your nose run?
- Finding:Followed up on nasal symptoms
- Finding:Denies itchy nose
(Available)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.Example Question:
Does your nose itch?
Finding:
Denies sinus pain
(Available)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.Example Question:
Do you feel any sinus pain?- Finding:Denies sinus pressure
(Available)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.Example Question:
Do you feel any sinus pressure? - Finding:Denies sneezing
(Available)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.Example Question:
Have you been sneezing?
- Finding:Followed up about character of nasal discharge
Finding:
Reports clear discharge
(Found)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.Example Question:
What color is your mucus?- Finding:Reports thin discharge
(Found)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.Example Question:
Is the mucus thick?
Finding:
Denies pus
(Available)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.Example Question:
Does your mucus have pus in it?
Finding:
Asked about eye symptoms
Finding:
Reports eye itching is constant
(Available)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.Example Question:
Do your eyes constantly itch?
Finding:
Reports eye redness
(Found)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.Example Question:
Are your eyes red?
Finding:
Asked related respiratory symptoms
Finding:
Reports breathing isn’t affected
(Found)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.Example Question:
Have you had any changes in your breathing?
Finding:
Denies cough
(Available)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.Example Question:
Do you have a cough?
Finding:
Denies chest tightness
(Available)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.Example Question:
Does your chest feel tight?
Finding:
Asked about related asthma symptoms
Finding:
Denies recent wheezing
(Found)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.Example Question:
Have you been wheezing?
Finding:
Denies increase in recent asthma symptoms
(Available)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.Example Question:
Has your asthma been worse lately?
Finding:
Asked about perceived cause of symptoms
Finding:
Reports symptoms are similar to allergies
(Found)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.Example Question:
Do you know what’s causing your symptoms?
Finding:
Reports symptoms don’t seem like a common cold
(Found)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.Example Question:
Do you think you have a cold?
Finding:
Reports similarity to her sister’s hay fever symptoms
(Found)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.Example Question:
Do you think you are having an allergic reaction?
Finding:
Asked about relieving factors for nose and eye symptoms
Finding:
Denies treatment for itchy eyes
(Found)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.Example Question:
Have you treated your eyes with anything?
Finding:
Denies treatment for nasal symptoms
(Available)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.Example Question:
Have you done anything for your runny nose?
Finding:
Denies taking antihistamine
(Available)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.Example Question:
Have you taken any antihistamines?
Finding:
Denies taking decongestant
(Available)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.Example Question:
Have you taken any decongestants?
Finding:
Asked about relieving factors for throat symptoms
Finding:
Reports lozenges as treatment
(Found)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.Example Question:
Have you taken anything for your sore throat?
Finding:
Reports lozenges reduce symptoms
(Available)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.Example Question:
Do the lozenges help?
Finding:
Reports ingesting lozenges every few hours
(Available)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.Example Question:
How often do you have a lozenge?
Finding:
Reports drinking water reduces symptoms
(Found)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.Example Question:
Does drinking water help?
Home Medications
Finding:
Confirmed home medications
Finding:
Reports no new medications
(Found)
Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.Example Question:
Have you started taking any new medications?
Finding:
Followed up about inhaler use
Finding:
Reports using an inhaler to treat asthma symptoms
(Found)
Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.Example Question:
Do you use an inhaler for your asthma?
Finding:
Reports inhaler is albuterol (Proventil)
(Found)
Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.Example Question:
What is the name of the inhaler you are currently using?
Finding:
Reports last use of inhaler was 1 week ago
(Available)
Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.Example Question:
When did you last use your inhaler?
Finding:
Reports typical inhaler use is 2 – 3 times a week
(Found)
Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.Example Question:
How often do you use your inhaler?
Finding:
Reports using 2 – 3 puffs of inhaler when used
(Available)
Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.Example Question:
How many puffs of your inhaler do you use?
Finding:
Reports prescribed dosage is 2 puffs
(Available)
Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.Example Question:
How many puffs of your inhaler are you supposed to do?
Social Determinants of Health
Finding:
Asked about environmental exposure to allergens
Finding:
Denies exposure to cats
(Found)
Pro Tip: Asking a patient about Social Determinants of Health (SDOH) can unearth underlying social, political, or economic barriers to their health and wellbeing. Recognizing a patient’s SDOH can lead you to provide more informed and empathetic care for your patients, because you will have a greater understanding of the challenges they face.Example Question:
Have you been recently exposed to any allergens?
Finding:
Denies exposure to mold or mildew
(Available)
Pro Tip: Asking a patient about Social Determinants of Health (SDOH) can unearth underlying social, political, or economic barriers to their health and wellbeing. Recognizing a patient’s SDOH can lead you to provide more informed and empathetic care for your patients, because you will have a greater understanding of the challenges they face.Example Question:
Do you have mold in your house?
Finding:
Denies exposure to dust
(Found)
Pro Tip: Asking a patient about Social Determinants of Health (SDOH) can unearth underlying social, political, or economic barriers to their health and wellbeing. Recognizing a patient’s SDOH can lead you to provide more informed and empathetic care for your patients, because you will have a greater understanding of the challenges they face.Example Question:
Do you have dust in your house?
Finding:
Denies exposure to irritants in work environment
(Found)
Pro Tip: Asking a patient about Social Determinants of Health (SDOH) can unearth underlying social, political, or economic barriers to their health and wellbeing. Recognizing a patient’s SDOH can lead you to provide more informed and empathetic care for your patients, because you will have a greater understanding of the challenges they face.Example Question:
Are you allergic to anything at work?
Finding:
Reports changing bedding once a week
(Available)
Pro Tip: Asking a patient about Social Determinants of Health (SDOH) can unearth underlying social, political, or economic barriers to their health and wellbeing. Recognizing a patient’s SDOH can lead you to provide more informed and empathetic care for your patients, because you will have a greater understanding of the challenges they face.Example Question:
How often do you change your bedding?
Finding:
Denies history of cigarette smoking
(Found)
Pro Tip: Asking a patient about Social Determinants of Health (SDOH) can unearth underlying social, political, or economic barriers to their health and wellbeing. Recognizing a patient’s SDOH can lead you to provide more informed and empathetic care for your patients, because you will have a greater understanding of the challenges they face.Example Question:
Have you smoked cigarettes recently?
Finding:
Denies recent exposure to secondhand smoke
(Available)
Pro Tip: Asking a patient about Social Determinants of Health (SDOH) can unearth underlying social, political, or economic barriers to their health and wellbeing. Recognizing a patient’s SDOH can lead you to provide more informed and empathetic care for your patients, because you will have a greater understanding of the challenges they face.Example Question:
Have you been exposed to secondhand smoke recently?
Finding:
Asked about healthcare access
Finding:
Reports last vision exam was in childhood
(Found)
Pro Tip: Asking a patient about Social Determinants of Health (SDOH) can unearth underlying social, political, or economic barriers to their health and wellbeing. Recognizing a patient’s SDOH can lead you to provide more informed and empathetic care for your patients, because you will have a greater understanding of the challenges they face.Example Question:
When was your last vision test?
Finding:
Reports last hearing test was in childhood
(Available)
Pro Tip: Asking a patient about Social Determinants of Health (SDOH) can unearth underlying social, political, or economic barriers to their health and wellbeing. Recognizing a patient’s SDOH can lead you to provide more informed and empathetic care for your patients, because you will have a greater understanding of the challenges they face.Example Question:
When was your last hearing test?
Finding:
Reports dental visit within the last 2 years
(Available)
Pro Tip: Asking a patient about Social Determinants of Health (SDOH) can unearth underlying social, political, or economic barriers to their health and wellbeing. Recognizing a patient’s SDOH can lead you to provide more informed and empathetic care for your patients, because you will have a greater understanding of the challenges they face.Example Question:
When did you last see the dentist?
Finding:
Reports regular dental visits in childhood
(Available)
Pro Tip: Asking a patient about Social Determinants of Health (SDOH) can unearth underlying social, political, or economic barriers to their health and wellbeing. Recognizing a patient’s SDOH can lead you to provide more informed and empathetic care for your patients, because you will have a greater understanding of the challenges they face.Example Question:
How often did you see the dentist when you were a child?
Finding:
Denies vision insurance
(Available)
Pro Tip: Asking a patient about Social Determinants of Health (SDOH) can unearth underlying social, political, or economic barriers to their health and wellbeing. Recognizing a patient’s SDOH can lead you to provide more informed and empathetic care for your patients, because you will have a greater understanding of the challenges they face.Example Question:
Do you have vision insurance?
Finding:
Denies dental insurance
(Available)
Pro Tip: Asking a patient about Social Determinants of Health (SDOH) can unearth underlying social, political, or economic barriers to their health and wellbeing. Recognizing a patient’s SDOH can lead you to provide more informed and empathetic care for your patients, because you will have a greater understanding of the challenges they face.Example Question:
Do you have dental insurance?
Relevant Medical History
Finding:
Confirmed allergies
Finding:
Reports known allergy to cats
(Found)
Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.Example Question:
Can you confirm that you’re allergic to cats?
Finding:
Reports known allergy to dust
(Found)
Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.Example Question:
Are you allergic to dust?
Finding:
Denies seasonal allergies
(Found)
Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.Example Question:
Do you have seasonal allergies?
Review of Systems
Finding:
Asked about constitutional health
Finding:
Denies recent or frequent illnesses
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.Example Question:
Have you been sick recently?
Finding:
Denies chills
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.Example Question:
Have you had any chills?
Finding:
Denies fever
(Found)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.Example Question:
Have you had a fever?
Finding:
Reports low energy level
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.Example Question:
Have you felt fatigued?
Finding:
Denies nausea or vomiting
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.Example Question:
Have you felt nauseous?
Finding:
Asked about review of systems for head
Finding:
Reports occasional headaches
(Found)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.Example Question:
Do you ever get headaches?
Finding:
Denies current headache
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.Example Question:
Do you have a headache currently?
Finding:
Denies history of head injury
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.Example Question:
Have you ever had a head injury?
Finding:
Denies lightheadedness
(Found)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.Example Question:
Do you ever get lightheaded?
Finding:
Followed up on headaches
Finding:
Reports headaches occur once a week
(Found)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.Example Question:
How often do you get headaches?
Finding:
Reports headaches last a few hours
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.Example Question:
How long do your headaches last?
Finding:
Reports headaches feel tight and throbbing
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.Example Question:
How would you describe your headaches?
Finding:
Reports headache location is behind her forehead
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.Example Question:
Where do you feel your headaches?
Finding:
Reports headache pain as a 3 or 4
(Found)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.Example Question:
How would you rate your headache pain on a scale of 0 to 10?
Finding:
Reports treating headaches with acetaminophen (Tylenol)
(Found)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.Example Question:
How do you treat your headaches?
Finding:
Reports reading and studying seem to cause headaches
(Found)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.Example Question:
What seems to cause your headaches?
Finding:
Asked about review of systems for eyes
Finding:
Reports occasional blurry vision
(Found)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.Example Question:
Do you have blurry vision?
Finding:
Reports worsening vision
(Found)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.Example Question:
Has your vision gotten worse?
Finding:
Denies eye pain
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.Example Question:
Have you had eye pain?
Finding:
Denies dry eyes
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.Example Question:
Have you had dry eyes?
Finding:
Denies corrective lenses
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.Example Question:
Do you have glasses or contacts?
Finding:
Followed up on vision problems
Finding:
Reports blurry vision as fuzzy letters
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.Example Question:
Can you describe your blurry vision?
Finding:
Reports blurry vision occurs when reading for long periods
(Found)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.Example Question:
When do you get blurry vision?
Finding:
Reports blurry vision occurs after 2+ hours of reading
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.Example Question:
How long have you been reading when your vision gets blurry?
Finding:
Reports that blurry vision and headaches often coincide
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.Example Question:
Do you get headaches when you have blurry vision?
Finding:
Asked about review of systems for ears
Finding:
Denies general ear problems
(Found)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.Example Question:
Have you had ear problems?
Finding:
Denies change in hearing
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.Example Question:
Have you had any changes in your hearing?
Finding:
Denies ear pain
(Found)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.Example Question:
Have you had ear pain?
Finding:
Denies ear discharge
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.Example Question:
Have you noticed ear discharge?
Finding:
Asked about review of systems for nose
Finding:
Denies change in sense of smell
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.Example Question:
Have you had any changes in your sense of smell?
Finding:
Denies nasal or sinus surgeries
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.Example Question:
Have you ever had a nasal surgery?
Finding:
Denies nosebleeds
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.Example Question:
Do you ever get nosebleeds?
Finding:
Asked about review of systems for mouth and jaw
Finding:
Denies general mouth problems
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.Example Question:
Have you ever had problems with your mouth?
Finding:
Denies change in sense of taste
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.Example Question:
Has your sense of taste changed?
Finding:
Denies dry mouth
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.Example Question:
Have you had dry mouth recently?
Finding:
Denies history of oral surgery
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.Example Question:
Have you ever had oral surgery?
Finding:
Denies mouth pain
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.Example Question:
Do you have mouth pain?
Finding:
Denies mouth sores
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.Example Question:
Do you have any mouth sores?
Finding:
Denies gum problems
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.Example Question:
Do you have any problems with your gums?
Finding:
Denies tongue problems
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.Example Question:
Do you have any problems with your tongue?
Finding:
Denies jaw problems
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.Example Question:
Do you have any problems with your jaw?
Finding:
Asked about review of systems for dentation
Finding:
Denies current dental problems
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.Example Question:
Do you have any current dental problems?
Finding:
Reports a few cavities in childhood
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.Example Question:
What dental problems have you had?
Finding:
Asked about review of systems for neck, throat and glands
Finding:
Denies history of recurrent strep throat
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.Example Question:
Do you get strep throat often?
Finding:
Denies lymph node problems
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.Example Question:
Do you have any problems with your lymph nodes?
Finding:
Denies history of general throat problems
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.Example Question:
Do you have a history of throat problems?
Finding:
Denies voice changes
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.Example Question:
Have you noticed any changes to your voice?
Finding:
Denies history of tonsil problems
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.Example Question:
Do you have any history of tonsil problems?
Finding:
Denies general neck pain
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.Example Question:
Do you have neck pain?
Relevant Family History
Finding:
Asked about relevant family history
Finding:
Reports sister with hay fever
(Found)
Pro Tip: A patient’s family medical history can indicate if the patient is at a higher risk for certain illnesses and disorders. Gathering this information can contextualize a patient’s current complaint and how their family’s health history might be influencing it.Example Question:
Do you have any family members with allergies?
Finding:
Denies family history of vision problems
(Available)
Pro Tip: A patient’s family medical history can indicate if the patient is at a higher risk for certain illnesses and disorders. Gathering this information can contextualize a patient’s current complaint and how their family’s health history might be influencing it.Example Question:
Do vision problems run in your family?
Finding:
Denies family history of sinus problems
(Available)
Pro Tip: A patient’s family medical history can indicate if the patient is at a higher risk for certain illnesses and disorders. Gathering this information can contextualize a patient’s current complaint and how their family’s health history might be influencing it.Example Question:
Do sinus problems run in your family?
Finding:
Denies family history of ear or hearing problems
(Available)
Pro Tip: A patient’s family medical history can indicate if the patient is at a higher risk for certain illnesses and disorders. Gathering this information can contextualize a patient’s current complaint and how their family’s health history might be influencing it.Example Question:
Do hearing problems run in your family?
Finding:
Denies family history of mouth, throat, or gland problems
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(Found)
Pro Tip: A patient’s family medical history can indicate if the patient is at a higher risk for certain illnesses and disorders. Gathering this information can contextualize a patient’s current complaint and how their family’s health history might be influencing it.Example Question:
Do you have any family history of throat problems?
Finding:
Denies family history of headache or migraine