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        Subjective: CC: “I have pain and swelling in my joints ” HPI:. Please start with demographics: AA, a 29 y.o. Asian female presents to the clinic alone with complaint of _____________. Onset, Location, Duration, Characteristics/context, Aggravating factors or Associated symptoms, Relieving Factors, Treatment, and Timing, Severity. Include any pertinent positives or negatives. Past Medical History: ● Medical problem list ● Preventative care: (if applicable to the case - Paps, mammography, colonoscopy, dates of last visits, etc.) ● Surgeries: ● Hospitalizations: ● LMP, pregnancy status, menopause, etc. for women Allergies: Food, drug, environmental Medications: include names, doses, frequency, and routes, and reason in parenthesis if off-label or secondary use Family History: Social History: -Sexual history and contraception/protection (as applies to the case) -Chemical history (tobacco/alcohol/drugs) (ask every pt about tobacco use) Other: -Other social history as applicable to each case (diet/exercise, spirituality, school/work, living arrangements, developmental history, birth history, breastfeeding, ADLs, advanced directives, etc. Exercise your critical thinking here - what is pertinent and necessary for safe and holistic care) ROS (write out by system): Comprehensive (>10) ROS systems for wellness exams or complex cases only. Do not include all 14 systems for every SOAP unless needed - review and document the pertinent systems. Do not include diagnoses - those belong in PMH. The below categories are per CMS guidelines. Constitutional: Eyes: Ears/Nose/Mouth/Throat: Cardiovascular: Pulmonary: Gastrointestinal: Genitourinary: Musculoskeletal: Integumentary & breast: