Previous and current medical conditions:
Document any diagnosed medical
conditions the client has or has had in the
past. This includes chronic illnesses, such as
diabetes, hypertension, asthma, as well as
acute conditions like pneumonia or urinary
tract infections.
Allergies:
Document any known allergies, including
medication allergies, food allergies, and
environmental allergies. This information
helps prevent adverse reactions or
interactions during medical interventions.
Immunization history:
Keep track of the client's immunization
records, including dates and types of
vaccines received. This information helps
ensure proper vaccination schedules and
identifies any gaps or booster requirements.
Surgical history:
Record any previous surgeries the client
has undergone. This information is crucial
as it may impact future medical decisions
and treatment plans.
Family medical history:
Gather information about the client's
immediate family members (parents,
siblings, and children) and their medical
history. Certain conditions, such as heart
disease, cancer, or genetic disorders, can
have a familial component, so it's important
to identify potential risks.
Medications:
List all current medications the client is taking,
including prescription drugs, over-the-counter
medications, and dietary supplements. Include
details about the dosage, frequency, and
duration of use. This information is vital for
avoiding medication interactions and
monitoring treatment effectiveness.
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Medical History
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