Patient has no significant PMH, PSH, FH, SH, takes no medications, and has no allergies. Specifically, personal and family cardiovascular histories are negative:
No history of exertional chest pain or discomfort,
No excessive exertional or unexplained dyspnea or fatigue,
No syncope or near syncope,
No hx heart murmur,
No HTN.
No FHx of premature heart-related death or SCD.
No FHx of disability from heart disease in close relative <50,
No FHx of hypertrophic / dilated CMP, ion channelopathy, long QT, Marfan, or arrhythmia.
No history of pulmonary disease, trauma, broken bones, concussion. Immunizations UTD.
No doctor has never denied or restricted the pt’s participation in sports for any reason.
No prior testing for the heart disease has ever been ordered for this patient.
Immunizations: Up to date.
HEADDRESS adolescent interviewing: normal.
Medications: None
Allergies: NKDA
Reference
http://www.aafp.org/afp/2015/0901/p371.html