Past, Family, and Social History:
Patient’s past experiences with illnesses, operations, injuries, treatments, medications, or allergies relevant to the condition being treated. (All medications and allergies are relevant.)
Diseases which are hereditary, or put the patient at risk. .
Past or current activities that are appropriate for patient (i.e. smoking – active or passive, drug use, alcohol use).
Level 99202 require none
Level 99203 require none
Level 99204 require at least 1
Level 99205 require at least 3
Level 99212 requires none
Level 99213 requires none
Level 99214 requires at least 1
Level 99215 requires at least 2
If the patient is unable to provide this information, document this fact in the chart and the reason. You will then be able to use the maximum number available.