PRACTICA 1 - 2º PARCIAL PRÁ CTICO

MEDICAL HISTORY FORM

INGLES TECNICO II MED 417
Nombre del Estudiante:
Número de Matrícula:
Fecha:

INSTRUCCIONES:

 La presente práctica tiene por objetivo que el estudiante pueda tomar una Anamnesis a un
paciente de manera completa y detallada en el idioma inglés. De esta forma reforzará sus
conocimientos en la materia y sobre el tema avanzado.
 Debe leer minuciosamente y comprender el formulario que está a continuación (Johns
Hopkins), entenderlo en su totalidad y tomar a un paciente que el estudiante considere que
puede ayudarle en este proceso, brindándole información fidedigna sobre su estado de
salud y las quejas que puedan existir en tanto sus problemas y quejas actuales.
 Cada una de las partes del cuestionario debe ser llenada evitando dejar vacíos, ya que una
Anamnesis de rigor, debe ser completa y lo más precisa posible.
 El estudiante debe presentarse al paciente con mucho respeto, conseguir su consentimiento
informado y proceder a hacerle las preguntas de manera ordenada, coherente, lógica y
tomándose el tiempo que requiera la entrevista, sin apresurar demasiado al paciente. Si el
paciente no comprendiera algún término, el estudiante debe aclarar la pregunta de la mejor
manera posible.
 Una vez que haya conseguido la información necesaria, el estudiante puede hacer un
diagnóstico presuntivo que incluirá en la parte inferior, al margen del cuestionario
trabajado.
 El estudiante debe aclarar al paciente que toda la información brindada se mantendrá en
absoluta reserva, agradeciéndole por su tiempo y predisposición para cooperar.
 Como último paso, se debe subir a la plataforma el trabajo manteniendo el formato Word
en el tiempo establecido para la corrección y asignación de nota correspondiente, dentro
del tiempo establecido.
 No se reciben trabajos por WhatsApp, ya que todo debe concentrarse en la plataforma para
su revisión.
 El presente trabajo debe llevar una carátula simple, donde estén los datos principales del
estudiante como, Nombre completo, Matrícula, Carrera, Fecha, Título del tema, etc.
 PATIENT HISTORY FORM

Date: _______/_________/________
NAME: Birthdate: _____/______/_____
Last First M. I.
Age:___________ Sex:  F  M

How did you hear about this clinic?

Describe briefly your present symptoms:

Please list the names of other practitioners you have seen for this problem:

Psychiatric Hospitalizations (include where, when, & for what reason):

Have you ever had ECT? Have you had psychotherapy?

CURRENT MEDICATIONS
Drug allergies:  No  Yes To what?
Please list any medications that you are now taking. Include non-prescription medications & vitamins or supplements:
Name of drug Dose (include strength & number of pills per day) How long have you been taking this?
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.

PAST MEDICAL HISTORY

Do you now or have you ever had:

 Diabetes  Heart murmur  Crohn’s disease

 High blood pressure  Pneumonia  Colitis
 High cholesterol  Pulmonary embolism  Anemia
 Hypothyroidism  Asthma  Jaundice
 Goiter  Emphysema  Hepatitis
 Cancer (type) _________________  Stroke  Stomach or peptic ulcer
 Leukemia  Epilepsy (seizures)  Rheumatic fever
 Psoriasis  Cataracts  Tuberculosis
 Angina  Kidney disease  HIV/AIDS
 Heart problems  Kidney stones

Other medical conditions (please list):

PERSONAL HISTORY
Were there problems with your
birth? (specify)
Where were your born & raised?
What is your highest education? High school Some college College graduate Advanced degree
Marital status:  Never married  Married  Divorced  Separated  Widowed  Partnered/significant other
What is your current or past occupation?
Are you currently working? :  Yes  No Hours/week ______ If not, are you  retired  disabled  sick leave?
Do you receive disability or SSI?  Yes  No If yes, for what disability & how long?___________________________
Have you ever had legal problems? (specify)
Religion:

FAMILY HISTORY
IF LIVING IF DECEASED
Age (s) Health & Psychiatric Age(s) at death Cause
Father
Mother
Siblings

Children

EXTENDED FAMILY PSYCHIATRIC PROBLEMS PAST & PRESENT:

Maternal Relatives:

Paternal Relatives:
 SYSTEMS REVIEW

In the past month, have you had any of the following problems?

GENERAL NERVOUS SYSTEM PSYCHIATRIC

 Recent weight gain; how much____  Headaches  Depression
 Recent weight loss: how much____  Dizziness  Excessive worries
 Fatigue  Fainting or loss of consciousness  Difficulty falling asleep
 Weakness  Numbness or tingling  Difficulty staying asleep
 Fever  Memory loss  Difficulties with sexual arousal
 Night sweats  Poor appetite
 Food cravings
MUSCLE/JOINTS/BONES STOMACH AND INTESTINES  Frequent crying
 Numbness  Nausea  Sensitivity
 Joint pain  Heartburn  Thoughts of suicide / attempts
 Muscle weakness  Stomach pain  Stress
 Joint swelling  Vomiting  Irritability
Where?  Yellow jaundice  Poor concentration
 Increasing constipation  Racing thoughts
EARS  Persistent diarrhea  Hallucinations
 Ringing in ears  Blood in stools  Rapid speech
 Loss of hearing  Black stools  Guilty thoughts
 Paranoia
EYES SKIN  Mood swings
 Pain  Redness  Anxiety
 Redness  Rash  Risky behavior
 Loss of vision  Nodules/bumps
 Double or blurred vision  Hair loss
 Dryness  Color changes of hands or feet OTHER PROBLEMS:

THROAT BLOOD
 Frequent sore throats  Anemia
 Hoarseness  Clots
 Difficulty in swallowing
 Pain in jaw KIDNEY/URINE/BLADDER
 Frequent or painful urination
HEART AND LUNGS  Blood in urine
 Chest pain
 Palpitations Women Only:
 Shortness of breath  Abnormal Pap smear
 Fainting  Irregular periods
 Swollen legs or feet  Bleeding between periods
 Cough  PMS

WOMENS REPRODUCTIVE HISTORY:

Age of first period:
# Pregnancies:
# Miscarriages:
# Abortions:
Have you reached menopause? Y / N At what age?
Do you have regular periods? Y/ N
 SUBSTANCE USE

DRUG CATEGORY
Age when How much & How many When did Do you currently
(circle each substance used) you first how often did years did you you last use this?
used this: you use this? use this? use this?

ALCOHOL Yes □ No □

CANNABIS: Yes □ No □
Marijuana, hashish, hash oil

STIMULANTS: Yes □ No □
Cocaine, crack

STIMULANTS: Yes □ No □
Methamphetamine—speed, ice, crank
AMPHETAMINES/OTHER STIMULANTS:
Yes □ No □
Ritalin, Benzedrine, Dexedrine
BENZODIAZEPINES/TRANQUILIZERS:
Yes □ No □
Valium, Librium, Halcion, Xanax, Diazepam,
“Roofies”
SEDATIVES/HYPNOTICS/BARBITURATES:
Yes □ No □
Amytal, Seconal, Dalmane, Quaalude,
Phenobarbital
HEROIN
Yes □ No □
STREET OR ILLICIT METHADONE Yes □ No □
OTHER OPIOIDS:
Yes □ No □
Tylenol #2 & #3, 282’S, 292’S, Percodan,
Percocet, Opium, Morphine, Demerol,
Dilaudid
HALLUCINOGENS:
Yes □ No □
LSD, PCP, STP, MDA, DAT, mescaline,
peyote, mushrooms, ecstasy (MDMA),
nitrous oxide
INHALANTS:
Yes □ No □
Glue, gasoline, aerosols, paint thinner,
poppers, rush, locker room
OTHER:
Yes □ No □
specify)_______________________________
_____________________________________
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