Subjective/History Elements
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CONSTITUTIONAL: No fevers, unintentional weight loss, fatigue, night sweats
HEAD: No headache or pain
EARS: No ear pain, discharge, hearing loss, tinnitus, vertigo
EYES: No changes in vision, eye pain, diplopia, photophobia, scleral icterus
NOSE: No nasal discharge, coryza, sneezing, epistaxis
THROAT: No cough, sore throat, dysphagia, odynophagia,
RESP: No cough, dyspnea with rest or exertion, wheeze, or orthopnea
CV: No chest pain, palpitations, edema, decrease in exercise tolerance
GI: No abdominal pain, nausea, vomiting, diarrhea, constipation
GU: No dysuria, frequency, urgency, hematuria, nocturia, incontinence, dribbling
Male: Denies discharge, lesions, testicular pain
Female: Denies discharge, lesions, changes in dysmenorrhea
MSK: No new weakness, arthralgias, myalgias
SKIN: No diagnosed skin conditions, new lesions, rashes, discoloration, dryness, hair changesNeuro: No weakness, confusion, numbness, dizziness, imbalance
ENDOCRINE: No new heat/cold insensitivity
PSYCH: No new or worsening depression, anxiety, or insomnia, stress
SOC: No change in home, relationships, employment, substance use
CONSTITUTIONAL: No fevers, unintentional weight loss, fatigue, night sweats
HEAD: No headache or pain
EARS: No ear pain, discharge, hearing loss, tinnitus, vertigo
EYES: No changes in vision, eye pain, diplopia, photophobia, scleral icterus
NOSE: No nasal discharge, coryza, sneezing, epistaxis
THROAT: No cough, sore throat, dysphagia, odynophagia,
RESP: No cough, dyspnea with rest or exertion, wheeze, or orthopnea
CV: No chest pain, palpitations, edema, decrease in exercise tolerance
GI: No abdominal pain, nausea, vomiting, diarrhea, constipation
GU: No dysuria, frequency, urgency, hematuria, nocturia, incontinence, dribbling
Male: Denies discharge, lesions, testicular pain
Female: Denies discharge, lesions, changes in dysmenorrhea
MSK: No new weakness, arthralgias, myalgias
SKIN: No diagnosed skin conditions, new lesions, rashes, discoloration, dryness, hair changesNeuro: No weakness, confusion, numbness, dizziness, imbalance
ENDOCRINE: No new heat/cold insensitivity
PSYCH: No new or worsening depression, anxiety, or insomnia, stress
SOC: No change in home, relationships, employment, substance use

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