When? Gradual? Sudden? How often? Special time? Wake up at night? Cough
up anything? Blood? Hacking? Dry? Barking?
2. Shortness of Breath
Hard to breath? Severe? How long? What brings it on? Worse lying down?
Nose, Mouth & Throat
Subjective Data Nose
1. Discharge (runny nose is discharge purulent, mucoid, or bloody)
2. Frequent colds (upper respiratory infections)
3. Sinus pain
5. Epitaxis (nosebleeds how often, how much bleeding, color, one nostril
a. Frequent? Severe? Where? When did it start? How often?
2. Head injury
a. Have you ever? What part of your head? Loss of consciousness?
3. Vertigo (dizziness)
a. Lightheaded? Faint? How often? Activity? Wh
Heart and Neck Vessels
1. Chest pain
Pain? Tightness? When? How long? Had it before? Where? Stabbing?
Burning? What worsens it?
Shortness of breath? What brings it on? Unexpected? Lying down? Awaken
you from sleep?
Skin, Hair & Nails
1. Previous history of skin disease (allergies, hives, psoriasis, eczema)
2. Change in pigmentation
3. Change in mole (size or color)
4. Excessive dryness or moisture
6. Excessive bruising
7. Rash or lesion (
Cellular metabolism requires a mean stable (deep body) temperature of 37.2C.
The normal oral temperature in a resting patient ranges from 35.8C to 37.3C. The
rectal temperature measures 0.4C to 0.5C higher
3. Discharge (pus or bloody, odor, any relation to ear pain)
4. Hearing loss
5. Environmental noise (at home or on the job)
6. Tinnitus (ringing, cracking, buzzing in ears)
7. Vertigo (room spinning around or