Hi, I’m ________________. I’m a Nurse Practitioner student at Walden
University and I’ll be completing your appointment today. I’d like to begin
by asking a few questions about yourself:
ID and Personal Hx
Can you please tell me your name and date of birth?
And how would you like me to address you?
Great, ____________, and please call me ________.
Before we get started, do you have any hearing or vision impairment that
may hinder the interview?
And how old are you?
What ethnicity to you identify as?
Where were you born?
And what about your parents?
What is your preferred language?
What’s your marital status?
What’s your occupation?
And what’s your highest level of education?
Chief Complaint and Hx of Present Illness
So tell me what brings you in today. My left ear has been hurting
Did it begin gradually or was the onset sudden? Sudden
When did your left ear begin hurting? About 3-4 days
Can you show me where the pain is located?
Have you noticed any drainage from your ear?
Can you describe the pain? Is it sharp, dull, aching? Aching
Does anything make it feel better or worse? Motrin helps a little. And heat
seems to help some too.
How severe is the pain? Does it interfere with your daily activities? It wakes
me up at night.
Past Medical Hx
Juan, next I’d like to discuss your health history:
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- Summer '15
- Diabetes, Past medical hx
