History of Present Illness (HPI) Evaluation Form
Please provide detailed information about your current medical concern to assist in your clinical assessment.
Patient Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Chief Complaint (What is the main reason for your visit?)
*
When did your symptoms begin?
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
How would you describe your symptoms? (e.g., pain, swelling, cough, etc.)
*
How severe are your symptoms?
*
Mild
1
2
3
4
5
6
7
8
9
Severe
10
1 is Mild, 10 is Severe
Are your symptoms constant or do they come and go?
*
Constant
Intermittent
Other
What makes your symptoms better or worse?
Have you tried any treatments or medications for this issue? If yes, please specify.
Are you experiencing any of the following associated symptoms? (Select all that apply)
Fever or chills
Nausea or vomiting
Shortness of breath
Chest pain
Dizziness
None of the above
Other
Do you have any chronic medical conditions?
Diabetes
Hypertension
Asthma
Heart disease
None
Other
Please list your current medications (including over-the-counter and supplements).
Do you have any allergies to medications or other substances?
No known allergies
Yes (please specify)
Do you have any relevant surgical history?
No
Yes (please specify)
Submit HPI Evaluation
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