Past Medical History Checklist
Past Medical History Checklist
General Items
- Review of systems (any new or ongoing symptoms)
Chronic Conditions
- Hypertension
- Diabetes Mellitus
- Asthma or COPD
- Heart Disease
- Chronic Kidney Disease
- Cancer (type and treatment)
Previous Surgeries
- Appendectomy
- Cholecystectomy
- Cardiac Surgery
- Orthopedic Surgery
- Any other significant surgeries
Allergies
- Medications (list specific drugs)
- Food (list specific foods)
- Environmental (e.g., pollen, dust)
Infectious Diseases
- HIV/AIDS
- Hepatitis B or C
- Tuberculosis
- COVID-19 (and vaccination status)
Family History
- Heart Disease in family members
- Diabetes in family members
- Cancer in family members (type)
Medications
- Current prescription medications (list names and doses)
- Over-the-counter medications (list names)
- Supplements (list names)
Generated from Panda Checklist
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