The document outlines a comprehensive approach to gathering a patient's medical history, including details about their current illness, past medical history, family dynamics, personal history, and mental status examination. It emphasizes the importance of chronological documentation of symptoms, family health history, and individual experiences from birth through adulthood. Additionally, it provides guidelines for assessing mental functioning, including mood, thought processes, perception, and cognitive abilities.
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Case history - long form
The document outlines a comprehensive approach to gathering a patient's medical history, including details about their current illness, past medical history, family dynamics, personal history, and mental status examination. It emphasizes the importance of chronological documentation of symptoms, family health history, and individual experiences from birth through adulthood. Additionally, it provides guidelines for assessing mental functioning, including mood, thought processes, perception, and cognitive abilities.