The Chief Complaint

Vital Signs

History of the Present Illness

Review of Medications

Allergies

Medical History

Surgical History

Family History

Social History

Review of Symptoms of Organ Systems

 

Physical Exam

Diagnostic Tests - General Considerations

Laboratory Testing

Screening for Asymtpomatic Disease

References

1. Preface. In: Goldberg C. eds. Practical Guide to History Taking, Physical Exam, and Functioning in the Hospital and Clinic. McGraw Hill; 2025. Accessed August 03, 2024. https://accessmedicine.mhmedical.com/content.aspx?bookid=3505&sectionid=288414412

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https://medicine.ucsf.edu/education/resed/articles/jama6_the_process.pdf

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