Weight Loss History
- CC:
- What is the current weight and height? (calculate BMI)
- How much did you lose?
- Over how long?
- Was it intentional?
- Onset: first time? Sudden\gradual? Continuous\intermittent?
- Severity: interfering w\ ADL?
Associated sx:
- Constitutional: fever, loss of appetite, night sweats, chills?
- GI: abdominal pain, N\V, change in bowel habits (diarrhea)?
- Decreasedoralintake: difficulty swallowing, painful mouth ulcers, early satiety?
- Eatingdisorder: fear of gaining wt, feel fat, binge eating (episodes of uncontrollable eating), self-induced vomiting?
- Depression: low mood, loss of interest?
- Hyperthyroid: heat intolerance, palpitations, tremor, menstrual changes?
- Cardiacfailure: SOB, LL swelling?
- Respiratory: chest pain, cough, hemoptysis?
- Liver: jaundice?
- DM: polyuria, polyphagia, polydipsia?
-
Urinary: dysuria, hematuria?
- Diet:
-
Recent change in diet habits?
-
How many meal\snacks per day?
-
What type of food do you usually eat?
-
Do you exercise?
- PMHx:
-
Diseases:
- Chronic ds (HTN, DM, DLP)
- Anemia, Hyperthyroidism
- Infections, malignancy
-
Medications: laxatives, diuretics, OTC, herbals
-
Surgery, hospitalization, trauma
-
Blood transfusions, IV drug use, tattoos
-
Allergies
- FMHx:
-
Similar complaint?
-
Same diseases as in PMHx?
- Social Hx:
-
Occupation, marital status, children?
-
Smoking, alcohol, recreational drugs?
-
Travel Hx
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