Abdominal pain:

Since : _______days/weeks/months/years

Continuous / intermittent

If episodic : frequency once in _____days/weeks/months/ regularly present

Duration of each episode : _____ minutes/ hrs

Site : Epigastric / umbilical / upper right quadrant / upper left quadrant / lower left quadrant /
right iliac fossa / lower abdomen / diffuse / variable

Factor Food Position Physical Antacids vomiting / Defecation

exertion Diarrhea
Aggravated
by
Relieved by

Severity – mild / moderate / severe

Character of pain : burning / colicky

Radiation of pain if any :

Associated symptoms :

Anorexia / Vomiting / diarrhea / constipation / back pain / burning micturition /

jaundice / haematuria / haematemesis / bloody stools / abdominal distension

Relevant history :

 h/o NSAID intake :

dyspeptic symptoms:
 fullness immediately after a meal
 early satiety
 sour eructation
 Abdominal bloating
 Urge to defecate soon after meal
  belching / burping
 flatulence

h/s/o intestinal parasites

Vomiting :
Since _______ days

_____times per day

Character : food / bilious

haematemesis +/-

 number of episodes : ______ _______,

 colour – dark / fresh blood [quantity - _____ml/few drops]
 associated anorexia/ dysphagia + / -

If projectile + / -

Associated symptoms : nausea / fever / diarrhea / drug intake / giddiness / weight loss

If side effect : name of drug : __________, taking since _______days

Diarrhoea :
Since _____days/weeks/months/years

If repeated episodes : one episode in _____ days/weeks

_____times per day

Watery / semisolid / bulky

Relevant history : Fever / straining / abdominal pain / mucus in stools / bloody stools / weight
loss / abdominal mass

Change of food habits / exposure to contaminated food / whether other family members
affected / recent antibiotic exposure [in the past _____days/weeks, name of drug ______]

Relation to a particular type of food : outside food / milk and milk products / other

Constipation alternating with diarrhea + / -

Constipation:
Since _____days / weeks / months / years / childhood
Stool frequency once in ____days

Straining + / -

Quantity - Bulky / small

Pain / burning during defecation + / -

Bleeding per rectum +/-

 quantity - ______ml / blood tinged / few drops

 fresh blood / dark / black colored

Mass per rectum + / - autoreducible / manually reducible

Relevant history :

 Inadequate fibre in diet + / -

 Long term usage of laxative / purgative + / -

Jaundice + / -
Since ______days / weeks / months

Appreciable in: sclera only / both sclera and skin

h/o previous episodes + / -

 no. ____
 duration _____days / weeks / months
 treatment received native / allopathic

relevant history:

 contact with jaundiced patients

 family h/o jaundice
 k/c/o gallstones / h/o previous biliary tract surgery
 h/o alcohol intake
 h/o relevant drug intake
 h/o relevant occupational exposure
 blood transfusions
 k/c/o hepatitis A / B / C / D / E

color of stools : pale / normal

urine : dark colored / normal

hematuria
since ____days / weeks / months

frequency: ____times in ____ weeks / months

quantity of blood :

timing: beginning of micturition / all through / terminally