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 you a few questions:
*Before we get started, do you have any hearing or vision
impairments that may hinder this interview?*
***Also, if you feel uncomfortable answering any of the questions
asked, please let me know**
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 ________.
What ethnicity to you identify as?
What is your marital status?
Chief Complaint
So tell me what brings you in today? Stomach Ache
Hx of Present Illness
(O)Was the pain in your stomach sudden or did it gradually get
worse? Gradual
(L)Can you show me where the pain is located? Stomach (points)
(D) How long have you been experiencing this pain? Within the last
month off and on
(C) Can you describe the pain? Is it sharp, dull, aching? Aching pain
(A)/ (R) Is there anything that makes the pain better or worse? The
pain is worse when I eat later than normal
(T) How long does the pain usually last? It usually goes away after
I eat. Do you take any medications to ease the pain? Yes, Tylenol and
(S) On a scale of 0 to 10 (0 being no pain and 10 being the worse pain
you ever felt). How would you describe the severity of your pain?
About a 5
Past Medical Hx
Des, next I’d like to discuss your health history:

In general, how would you describe your overall health? Besides my
stomach issue, I am overall healthy
Have you had stomach issues in the past? If so what type of issue was
it? I was diagnosed with H. Pylori a few months ago as well as a
few years ago
What about surgeries? I had an EGD done both times
When was that? 2018 and 2013
Was there any other findings from the EGD? NO
Have you ever been hospitalized? No
Are your immunization current? Yes
When was your last tetanus shot? About 5 years ago
Are you prescribed any medications? Yes, Nexium
Besides Tylenol, do you take any over the counter medications or
supplements? Ibeprofen
Do you have any allergies? NO
Any history of blood transfusions? NO, if yes ask if there was any
blood transfusion reactions.
How do you describe your current emotional state? Have you ever
been hospitalized and treated for any psychiatric disorders? I am ok.
How would you describe your appetite? (low, high, normal) LOW, I’m
usually too busy to eat regularly
Do you have any diet restrictions? Yes, no caffeine
Do you take any vitamins or supplements? (Including workout
supplements such as pre-workout or energy drinks) NO
Describe your physical activity over the past week. I played soccer
once this week
How many minutes do you spend working out? About 30 mins 3x a
Drug/Alcohol Use

Have you ever smoked or used tobacco products including hookah?
Yes. I use hookah
How often do you smoke hookah? Occasionally with friends
Do you drink alcohol? Yes How often? Occasionally I am a
social drinker
Have you ever used illegal drugs or used prescription medications for
nonmedical reasons? NO
Health Maintenance
When was your last physical? Last month
When was your last eye exam?
And how would you describe the condition of your teeth and mouth?
Do you have dentures or false teeth?
Do you always wear your seatbelt when you are in a car?
Do you ever drive after drinking, or ride with a driver who has been
How many sexual partners have you had in the past year?
And when you have sex, do you prefer men, women, or both?
Do you use contraceptives or condoms during intercourse?
Do you snore? Yes.
And in the past seven days how frequently were you sleepy during the
Have you ever had your cholesterol tested?
Family Hx
Next, I would like to ask you some questions related to your family’s health.
Please let me know if a parent, grandparent, sibling, or child has been
diagnosed or treated with any of the following:
Any history of heart disease or high blood pressure?
What about stroke or sickle cell disease?
Any form of cancer? Yes, My father and mother
How old was your father when he was diagnosed?


Do you know what type of cancer it was? Lung Cancer
Was the cancer found in both lungs or just on the right or left side of
the lung?
What measures were taken to treat the cancer? And what was the
How old was your mother when she was diagnosed?
And do you know what type of cancer it was?
Was the cancer found in multiple locations?
What measures were taken to treat the cancer? And what was the
Diabetes? No
What about epilepsy or cystic fibrosis? No
Kidney disease or arthritis? No
Gout or thyroid disease? No
Hearing, visual, or any other sensory issues? No
Anyone suffer from asthma or any other allergic conditions? No
Personal/Social History
Do you consider yourself a sociable or friendly person?
What is your occupation?
What is the highest level of education you have completed? High
school, some college, bachelor’s degree, masters
Can you recall your day yesterday?
Can you recall what you ate within the last 24-hours?
*** Now, I have a few questions pertaining to your health and any symptoms
you may be having.
Review of Systems
Have you experienced any unexplained weight loss or gain, loss of
appetite, fever or night sweats? Are you feeling fatigued? No

Have you noticed any changes in your skin? Any rashes or persistent
Head and Neck, Neuro
Any issues with headaches? Have you experienced any loss of
consciousness, fainting, or weakness? Have you noticed any tremors? Any
neck or shoulder pain?
Any sudden changes in vision? Blurring or double vision?
Any difficulty hearing, hearing loss, or ringing in your ears?
Any congestion, nosebleeds, or postnasal drip?
Throat and Mouth
Any mouth sores, sore throat, or hoarseness? What about bleeding
Any change in bowel habits? Any issues with heartburn, constipation,
diarrhea or abdominal pain? Any difficulty swallowing, nausea or vomiting?
Have you noticed any swelling or tenderness in your lymph nodes?
Do you experience heat or cold intolerance? Increased thirst?
Changes in your hair such as hair loss or thinning?
Can you tell me when you entered puberty? Any issues with erections,
testicular pain, or libido?
Have you noticed any discharge from your nipples or pain or
tenderness in your chest area? Felt any lumps in the breast area?
Chest and Lungs

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Any shortness of breath or wheezing? Persistent cough or sputum?
Have you been exposed to TB or have an abnormal chest x-rays?
Have you noticed an irregular heartbeat, racing heart or heart
palpitations? What about chest pains, swelling of feet or legs or pain with
Have you ever been told you have anemia? Do you bruise easily?
Any pain with urination? What about urinary frequency, urgency, or
waking at night to urinate? Any dribbling or blood in your urine? Any pain
on either side of your back below your ribs?
Any joint pain or muscle aches? Have you noticed any joint
Mental Status
Have you noticed any difficulty concentrating? What about change in
appetite or sleeping difficulties? Any recent mood changes? Do you ever
have thoughts of suicide?
Are there any other concerns you would like to address with me

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