MINISTRY OF EDUCATION AND SCIENCE OF UKRAINE

V. N. KARAZIN KHARKIV NATIONAL UNIVERSITY

SCHOOL OF MEDICINE
DEPARTMENT OF PROPAEDEUTICS OF INTERNAL MEDICINE AND
PHYSICAL REHABILITATION

Head of department
PdD, assoc. prof. Mariia S. Brynza

MEDICAL HISTORY
Patient last name first name________________________
Clinical diagnosis________________________________

Your name, surname, group number

Teacher:
Assistant of department,
Dr. Nataliia Bogun

Kharkiv - 2020
 PASSPORT DATA
- Patient full name;
- Age;
- Marital status;
- Profession;
- Place of residence;
- Clinical diagnosis.
PATIENT COMPLAINTS
The main complaints. Each of the main complaints is analyzed (detailed) according to
the scheme. Detailing the main complaints allows us to associate their presence with
damage to certain organs or systems of the patient. The description of complaints is
carried out according to the system that is affected. Other systems are not reflected.
Additional complaints are characteristic of the pathology of different systems and
organs: general weakness, malaise, loss of working capacity, irritability, sleep
disturbance.
HISTORY OF THE PRESENT DISEASE (ANAMNESIS MORBI)
The main requirement for anamnesis is to reveal the dynamics of the pathological
process from the onset of the disease to the patient's admission to the clinic.
The section consists of 3 main, chronologically related parts:
1. The beginning, character, and features of the underlying disease.
The history of the present disease should reflect the causes and time of occurrence, as
well as the dynamics of the development of the disease from its onset to the present. If
the disease is chronic, then the first symptoms of the disease are described in detail, and
then the symptoms, the occurrence of relapses or exacerbation of the disease are
reflected in a chronological sequence, periods of remission, their duration are
highlighted. It is necessary to establish when the real deterioration occurred, about
which the patient was hospitalized in the clinic (exacerbation of the disease,
clarification of the diagnosis, etc.).
2. The results of laboratory and instrumental tests before admission to the hospital. In
this section, it is necessary to list the results of all laboratory and instrumental studies
performed before the patient admits to the clinic.
3. Prior treatment and its effectiveness. In this section, it is necessary to note the results
of the previous treatment.

PAST HISTORY (ANAMNESIS VITAE)

The section consists of 5 parts:
1. Physical and intellectual development of the patient:
 Bad habits: smoking (age at which she/he started smoking, the number of
cigarettes smoked per day); alcohol (age at which alcohol started to drink, frequency of
use); drugs (consumes or not).
 Other diseases in the past: considered in chronological order. It is necessary to
indicate at what age each disease or operation was; to clarify whether the patient had
Botkin’s disease, sexually transmitted diseases, tuberculosis (contact with patients with
tuberculosis).
2. Material conditions:
 housing conditions: apartment, house;
 marital status: single, married. Lives alone or in a family;
 nutrition: how many times a day, when and in what form food is taken. Whether
the meal is measured or fast. Hot food, drinks (tea, coffee) are taken moderately hot or
very hot. Is the patient getting enough vegetables? Does he consume fresh vegetables
and fruits and in what quantity;
 personal hygiene: change of underwear and bed linen (how often). Take a
shower, bath (how often). Oral hygiene (brushing teeth or not);
 non-working regime: when he gets up and lies down, what he does before leaving
for work and upon returning from it, the distance to the place of work from home and
ways of transportation.
3. Labor history:
 the patient's labor activity, outlined in chronological order. In relation to each
period, it is necessary to indicate for how long and at what age, at what enterprise, what
profession the patient was engaged in, give a brief description of the work with the
designation of occupational hazards, the length of the working day;
 work timetable: duration of work, break during work, day or night work, time or
piece work, the pace of work, responsibility for the work performed;
 how long the patient has been on sick leave over the last year; persistent disability
(does he have a disability group; if yes - when it was installed).
4. Allergic history. It is necessary to indicate whether there were immediate allergic
reactions (urticaria, Quincke's edema, anaphylactic shock) to medicines, vaccines,
serums, food products, plant pollen, insect bites, etc.; food allergies, reactions to blood
transfusion.
5. Hereditary history. Diseases in the family (mother, father, brothers, sisters,
grandparents) and hereditary diseases in the family are indicated.