- 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)?
- Decreased oral intake: difficulty swallowing, painful mouth ulcers, early satiety?
- Eating disorder: 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?
- Cardiac failure: 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
- Diseases:
- FMHx:
- Similar complaint?
- Same diseases as in PMHx?
- Social Hx:
- Occupation, marital status, children?
- Smoking, alcohol, recreational drugs?
- Travel Hx