History of Present Illness Questionnaire - For Your PCP

Make the most out of a visit with your primary care physician by filling out this form and taking it with you when you go;


Where exactly do you feel the ache- make an outline of the front and back of a person and mark “x”s where you feel the sharpest strongest pain and “o”s where it radiates or if it moves around etc.



Describe the quality of the pain; sharp dull cramping stabbing burning pressure pulling etc and how it changes etc;



Describe the severity of the discomfort, how bad is it at its worst best on average and how long does it usually stay at the different levels etc;



Describe the timing of the pain- day or night? wakes from sleep? constant intermittent? etc;



Describe any factors that seem to modify the pain- make it better or worse and specify if they make it better or worse; eating pooping peeing drinking exertion rest certain activities postures etc;



What if any treatments have you tried so far? Include physical modalities like physical therapy acupuncture etc, over the counter treatments or Rx treatments. Have any of them helped, what hasn’t worked in the past?



What diagnostic tests (specific blood test, X ray, Cat Scan MRI, Stress Test, internal scope procedure or surgical tests etc.) have been done so far to evaluate the problem? Who ordered or did the tests? When were they done and what if anything did they show?



Describe any associated signs or symptoms- fever chills nausea sweats weight loss dizziness shortness of breath belly cramps etc. that seem to come on along with the pain if you have noticed any.