EXAMPLE 1: ONE SYMPTOM
CHIEF COMPLAINT (CC)
CHIEF COMPLAINT What is the one symptom -or- the related symptom set you most need this appointment to document and address? | increase in fatigue from baseline |
HISTORY OF PRESENT ILLNESS
LOCATION Where is CC located? | full body. deep fatigue. |
QUALITY What is the quality of CC? Sharp? Stabbing? Dull? Aching? Improving or worsening? | consistently worsening |
SEVERITY How severe is CC? How disruptive is it? Are there things you cannot do because of it? What number is it on the pain scale? | cannot get out of bed more than an hour, make meals or stand in shower |
ONSET When did CC begin? How long has it been going on for? Is this your first time experiencing CC? | six weeks ago have chronic fatigue but this is markedly worse from baseline |
TIMING Is CC episodic? Waxing and waning? Constant? Unpredictable? Variable? Dynamic? | constant but varies in severity |
CONTEXT Is CC associated with any activities? | any time I am out of bed |
MODIFYING FACTORS What makes CC better? What makes it worse? Activities? Postures? Medicines? | worsen with activity does not improve with rest |
ASSOCIATED SYMPTOMS Are there any other symptoms that may be significant or related to CC? | increase in photosensitivity which is usually associated with my autoimmune conditions |
OTHER CONSIDERATIONS
QUALITY OF LIFE (QOL) How does CC affect your quality of life? | it is worsening my quality of life |
ACTIVITIES OF DAILY LIVING (ADL) How does CC affect your activities of daily living? (Moving positions, dental hygiene, physical hygiene, eating, ambulation/walking/moving, conversing, etc) | cannot make food cannot get up from bed cannot stand in shower cannot walk much or converse |
EXAMPLE 2: RELATED SYMPTOM SET
CHIEF COMPLAINT (CC)
CHIEF COMPLAINT What is the one symptom -or- the related symptom set you most need this appointment to document and address? | neck pain with facial numbness, sore throat, inner ear pain, nerve zaps and difficulty swallowing |
HISTORY OF PRESENT ILLNESS
LOCATION Where is CC located? | neck pain: exclusively left side of neck, three fingers below ear all other symptoms: left side of face and neck |
QUALITY What is the quality of CC? Sharp? Stabbing? Dull? Aching? Improving or worsening? | side of face: numbing, buzzing, zapping pain inner ear: aching throat: sore side of neck: dull, aching or sharp overall: worsening |
SEVERITY How severe is CC? How disruptive is it? Are there things you cannot do because of it? What number is it on the pain scale? | at worst, 8/10 pain sometimes can’t eat, speak or sleep because of it |
ONSET When did CC begin? How long has it been going on for? Is this your first time experiencing CC? | this symptom set first began all together 5 months ago |
TIMING Is CC episodic? Waxing and waning? Constant? Unpredictable? Variable? Dynamic? | neck pain is near constant. sometimes I have episodes of greater severity. some symptoms are unpredictable. |
CONTEXT Is CC associated with any activities? | can provoke facial numbness, sore throat, zapping and inner ear pain by pressing below my ear or turning head left. sometimes not associated with anything. |
MODIFYING FACTORS What makes CC better? What makes it worse? Activities? Postures? Medicines? | worsens with forward head posture or if I am upright for too long. improves with SCM and Scalene massage by PT. |
ASSOCIATED SYMPTOMS Are there any other symptoms that may be significant or related to CC? | headaches when I turn my head to the left. seems to coincide with other symptoms. |
OTHER CONSIDERATIONS
QUALITY OF LIFE (QOL) How does CC affect your quality of life? | constant pain worsens my quality of life |
ACTIVITIES OF DAILY LIVING (ADL) How does CC affect your activities of daily living? (Moving positions, dental hygiene, physical hygiene, eating, ambulation/walking/moving, conversing, etc) | interfering with my ability to do PT. Limits ability to be upright and converse. |