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123 Main street
30- DOB 05/02/1988
Associates degree in Nursing
Health Insurance- Florida Blue
“I hurts when I urinate”
Includes when the problem started- “3 days ago”
History of Present Illness:
P – Provocative or palliative (“It hurts when I urinate”
Q – Quality or quantity (Urine is yellow, “I have to urinate frequently”)
R – Region or radiation (Pelvic region).
S – Severity (8 from scale of 0-10).
T – Timing (Started happening 3 days ago)
U – Understand Patient’s Perception of the problem (What do you think it means?)
Past Medical History
Medical Hx: Patient denies
Childhood Illnesses: Patient denies
Obstetric HX: Number of pregnancies -0, term deliveries- 0, preterm births-0, abortions-0, number of children living-0
Immunizations: up to date