Section 1 — Patient Identification & Baseline
Medical History (check all that apply)
Allergy Types
Current Medications / Drug Classes
Section 2 — Chief Complaint & Onset
Pain / Symptom Quality (check all)
Location / Body Area
Section 3 — Modalities
What makes it BETTER?
What makes it WORSE?
Section 4 — Associated Findings
Temperature Pattern
Thirst
Thirst Preference
Appetite
GI Findings
Discharge Character (nasal, ocular, etc.)
Sleep (past 48 hrs)
Section 5 — Mental / Emotional State
Emotional state since symptoms began (check all)
Did emotional stress, grief, anger, or shock precede this illness?
Section 6 — Constitutional & Recent Exposures
Alcohol / Caffeine intake (past week)
Previous treatment attempts for this episode
Unusual stress or recent travel?