1. Chief Complaint
1. Primary reason for visit: Document patient’s stated concern (e.g., "fatigue,"
"low mood," "pain").
2. History of Present Illness (HPI)
2. Onset & Duration:
o When did symptoms begin?
o Are they constant/intermittent?
3. Frequency & Timing:
o How often do symptoms occur?
o Time of day when worst?
4. Aggravating Factors:
o What makes symptoms worse? (e.g., activity, stress)
5. Relieving Factors:
o What helps? (e.g., rest, medications)
3. Depression Screening (PHQ-9 Domains)
6. Anhedonia:
o "Have you lost interest in activities you used to enjoy?"
7. Mood:
o "How often do you feel down or hopeless?"
8. Sleep:
o Trouble falling/staying asleep? Early awakenings?
9. Energy:
o "Do you feel fatigued most days?"
10. Appetite:
o Increased/decreased? Weight changes?
11. Self-Worth:
1. Primary reason for visit: Document patient’s stated concern (e.g., "fatigue,"
"low mood," "pain").
2. History of Present Illness (HPI)
2. Onset & Duration:
o When did symptoms begin?
o Are they constant/intermittent?
3. Frequency & Timing:
o How often do symptoms occur?
o Time of day when worst?
4. Aggravating Factors:
o What makes symptoms worse? (e.g., activity, stress)
5. Relieving Factors:
o What helps? (e.g., rest, medications)
3. Depression Screening (PHQ-9 Domains)
6. Anhedonia:
o "Have you lost interest in activities you used to enjoy?"
7. Mood:
o "How often do you feel down or hopeless?"
8. Sleep:
o Trouble falling/staying asleep? Early awakenings?
9. Energy:
o "Do you feel fatigued most days?"
10. Appetite:
o Increased/decreased? Weight changes?
11. Self-Worth:
