The order of the examination of body systems is roughly head to toe. The items within each system are not inclusive, and only the most common symptoms are listed.
When recording information, avoid writing "negative" after the system heading. You need to record the presence or absence of all symptoms; otherwise, the reader does not know about which factors you considered.
Health promotion sections should always be included in your health records. They provide you with an opportunity for you to motivate and persuade yourself to improve your health. Each person is different, consider ways that you can include information during your self-assessment.
General Overall Health State. Record your present weight (gain or loss, over what period of time, by diet or other factors), indicate any fatigue, weakness or malaise, fever, chills, sweats or night sweats you may be having
Skin, Hair, and Nails. Track a history of skin disease (eczema, psoriasis, hives), pigment or color change, change in mole, excessive dryness or moisture, pruritus, excessive bruising, rash or lesion). Indicate any recent hair loss or change in texture. Change in shape, color, or brittleness of nails.
Health Promotion. Amount of sun exposure; is it adequate yet safe? Consider your methods of self-care for skin and hair.
Head. Indicate if there is any unusually frequent or severe headaches; any head injury, dizziness (syncope), or vertigo?
Eyes. Record any difficulty with vision (decreased acuity, blurring, blind spots), eye pain, diplopia (double vision), redness or swelling, watering or discharge, glaucoma or cataracts.
Health Promotion. Do you wear glasses or contacts; indicate your last vision check or glaucoma test; how is coping with your loss of vision if any.
Ears. Check for Earaches, infections, discharge and its characteristics, tinnitus or vertigo.
Health Promotion. Consider any hearing loss, hearing aid use, how loss affects daily your life, any exposure environmental noise, and method of cleaning ears.
Nose and Sinuses. Review any nose discharge and its characteristics, any unusually frequent or severe, sinus pain, nasal obstruction, nosebleeds, allergies, hay fever, or change in sense of smell.
Mouth and Throat. Are you experiencing any mouth pain, frequent sore throat, bleeding gums, toothache, lesion in mouth or tongue, dysphagia, hoarseness or voice change, tonsillectomy, or altered taste.
Health Promotion. Could your pattern of daily dental care, use of dentures, bridge, and last dental checkups be improved?
Neck. Are you experiencing any pain, limitation of motion, lumps or swelling, enlarged or tender nodes, a goiter. Are there any recent injuries
Breast. Do you experience any pain, lumps, nipple discharge, rash, history of breast disease, or any surgery on breasts.
Health Promotion. Do you perform a breast self-examination? In clude a record including its frequency and method used. When was your last mammogram, is that enough?
Axilla. Look for any tenderness, lumps or swelling, a rash?
Respiratory System. History of lung diseases (asthma, emphysema, bronchitis, pneumonia, TB), chest pain with breathing, wheezing or noisy breathing, shortness of breath, how much activity produces shortness of breath, cough, sputum (color, amount), hemoptysis, toxin or pollution exposure.
Health Promotion. When was your last chest x-ray, or TB skin test.
Cardiovascular. Record any chest pain experienced recently, pressure, tightness or fullness, palpitation, cyanosis, dyspnea exertion (specify amount of exertion [e.g., walking one flight of stairs, walking from chair, or just talking]), orthopnea, paroxysmal nocturnal dyspnea, nocturia, edema, history of heart murmur, hypertension, coronary heart disease, or anemia.
Health Promotion. What was the date of your last ECG or other cardiac tests, cholesterol screening. How are you leveraging this information?
Peripheral Vascular. Indicate recent coldness, numbness, and tingling, swelling of legs (time of day, activity), discoloration in hands or feet (bluish red, pallor, mottling, associated with position, especially around feet and ankles), varicose veins or complications, intermittent claudication, thrombophlebitis, or ulcers.
Health Promotion. Does the work involve long-term sitting or standing? Does the patient frequently cross his or her legs at the knees? Have you tried wearing support hose?
Gastrointestinal. Monitor your appetite, any food intolerances, dysphagia, heartburn, indigestion (associated with eating), other abdominal pain, pyrosis (esophageal and stomach burning sensation with sour eructation), nausea and vomiting (character), vomiting blood, history of abdominal disease (liver or gallbladder, ulcer, jaundice, appendicitis, colitis), flatulence, frequency of bowel movement, any recent change, stool characteristics, constipation or diarrhea, black stools, rectal bleeding, and rectal conditions (hemorrhoids, fistula).
Urinary System. Record the frequency, urgency, nocturia (the number of times the person awakens at night to urinate, recent change); dysuria; polyuria or oliguria; hesitancy or straining, narrowed stream; urine color (cloudy or presence of hematuria); incontinence; history of urinary disease (kidney disease, kidney stones, urinary tract infections, prostate); pain in flank, groin, suprapubic region, or lower back.
Health Promotion. Measures you use to avoid or treat urinary tract infections, use of Kegel exercises after childbirth.
Male Genital System. Inspect the penis or record any testicular pain, sores or lesions, penile discharge, lumps, and hernia symptoms.
Health Promotion. Consider performing testicular self-examinations. How frequently?
Female Genital System. Record your menstrual history (age at menarche, last menstrual period, cycle and duration, any amenorrhea or menorrhagia, premenstrual pain or dysmenorrhea, intermenstrual spotting), vaginal itching, discharge and its characteristics, age at menopause, menopausal signs or symptoms, and postmenopausal bleeding.
Health Promotion. Last gynecologic checkup and last Pap test?
Sexual Health. Ask yourself: "Are you presently in a relationship involving intercourse? Are the aspects of sex satisfactory to you and your partner? Are condoms used routinely (if applicable)? Is there any dyspareunia (for female) or are there any changes in erection or ejaculation (for male)? Are contraceptives used (if applicable)? Is the contraceptive method satisfactory? Are you aware of contact with a partner who has any sexually transmitted infection (chlamydia, gonorrhea, herpes, venereal warts, HIV/acquired immunodeficiency syndrome [AIDS], or syphilis)?"
Musculoskeletal System. Record your history of arthritis or gout.
In the joints: Look for any pain, stiffness, swelling (location, migratory nature), deformity, limitation of motion, noise with joint motion?
In the muscles: Is there any muscle pain, cramps, weakness, gait problems, or problems with coordinated activities?
In the back: Is there any pain (location and radiation to extremities), stiffness,
limitation of motion, or history of back pain or disc disease?
Are there any recent injuries to the joints, muscles, or back?
Health Promotion. How much are your walking per day? What is the effect of limited range of motion on ADLs such as grooming, feeding, toileting, dressing? Are any mobility aids used?
Neurologic System. Record your history of any seizure disorder, stroke, fainting, and blackouts.
Motor function. Are you experiencing any weakness, tics or tremors, paralysis, or coordination problems?
Sensory function. Identify any numbness, tingling (paresthesia)?
Cognitive function. Record any memory disorders (recent or distant, disorientation)?
Mental status. Are you experiencing any nervousness, mood change, depression, or history of mental health dysfunction or hallucinations?
Health Promotion. Alternatively, capture data about interpersonal relationships and coping patterns could be placed here.
Hematologic System. Identify and explain any bleeding tendencies of skin or mucous membranes, excessive bruising, lymph node swelling, exposure to toxic agents or radiation, blood transfusion and reactions.
Endocrine System. Record your history of diabetes or diabetic symptoms (polyuria, polydipsia, polyphagia), history of thyroid disease, intolerance to heat and cold, change in skin pigmentation or texture, excessive sweating, relationship between appetite and weight, abnormal hair distribution, nervousness, tremors, and any need for hormone therapy.