History Taking Checklist

Date of taking history:

Name: Residency: Religion:
Gender: Date of Admission: Mode of referral:
Age: Marital Status: Mode of arrival:
Chief Complaint & Duration:

History of the Present illness:

Pain

Site

Onset

Character

Radiation

Duration

Severity

Exacerbating F.

Relieving F.

Associated Symptoms

☐ No ☐ Yes, List them

ROS: 2. Cardiovascular
1.General Chest pain on exertion ☐Dyspnea

☐Appetite ☐Water intake ☐Sleeping Site ☐Orthopnea

☐Weight (documented?) ☐Mood Onset ☐Noctural Dyspnea

☐Fever (documented?) Character ☐Palpitation (onset? duration? regularity?)

Site: Duration: Radiation ☐Edema (site? Pitting or not?)

Onset: Relieving F: Duration ☐Swollen ankles

Associated Symptoms: Exacerbating f. ☐Intermittent Claudication

☐Rigors ☐Chills ☐Sweating (Degree?) Relieving f. Additional notes:

Additional notes: Associated Symptoms

☐ No ☐ Yes, List them

3.Respiratory Chest pain due to inspiration

☐SOB on rest (When? Duration? Relieving f.?) Site: Breast

☐Cough Frequency: Duration Character: ☐Tenderness

Exacerbating f. Relieving f Radiation: ☐Lump

☐Sputum Color: amount: consistency: odor Duration: ☐Discharge

☐Wheeze Exacerbating f. ☐Swelling(R,L)

Additional notes: Relieving f. ☐Any change

Associated s.? in color/shape?

4.GIT 5.GU
☐Dysphagia Color of urine: amount:

☐Discomfort after eating(indigestion) frequency: blood? Describe.

☐Heartburn site? ☐Urgency ☐Hesitancy ☐Drippling

☐Excessive belching

☐Nausea with/without ☐Vomiting Men ONLY

Vomitus details: Describe the nature. Color: ☐Blood? ☐Genital rash(Describe)

Amount: Components: When? (relation to eating?) ☐Lumps(Describe)

Bowel habits ☐Constipation pain? ☐Any Discharge? (Describe)

☐Diarrhea Color? Pain? ☐Pain? (Describe)

☐Alternating ☐Incontinence

☐Melena Color? ☐ Rectal Bleeding ☐Prostatic problems? List.

☐Hematemesis Color? ☐ (If appropriate) Erectile Difficulties?

Abdominal Pain

Site Females ONLY

Onset: Menarche

Character: Regularity ☐on drugs? Amount:

Radiation: ☐Menopause ☐PMB? ☐Hot flushes?

Duration: ☐Menstrual pain? (Describe if abnormal)

Exacerbating f.

Relieving f. ☐Bleeding between periods?

Associated Symptoms ☐ (If appropriate) Painful intercourse?

☐ No ☐ Yes, List them ☐Pregnant ☐Contraception Method?

Additional notes: Type of labor:

No. of children? No. of miscarriages?

6.Nervous 7. Musculoskeletal
☐Headache (Describe the site, duration, etc.) Joint/Muscle Pain (Joints involved?)

☐Dizziness (Describe the site, duration, associated sym., etc.) Site

☐Faints ☐Coma (Describe what happened before/after?) Onset:

☐Fits? Character:

☐Limb weakness (Describe the site, nature) Duration

☐Numbness (Site?) Frequency:

☐Tremors? Radiation:

☐Concentration problems Exacerbating/Relieving f:

☐Vision problems ☐blurred ☐double vision Severity:

☐Hearing problems ☐↑ ☐↓ ☐tinnitus Associated symp.:

☐Difficulty with speech ☐stiffness ☐Frequent fractures

☐Swelling ☐Redness

☐Erythema/Warmth

8.Endocrine ☐Weakness ☐Limitation of movement

☐Heat intolerance ☐Dry mouth ☐Sore eyes

☐Cold intolerance ☐ Polydipsia

☐Neck swelling ☐Polyuria ☐Libido 9. Hematological

☐Fine tremor ☐Fatigue ☐Bleed excessively ☐ Bruise easily

☐Bleeding spots (Describe)

10.Mucocutaneous Lumps in ☐axilla ☐neck ☐groins

☐Hair loss ☐Skin rash (Describe.) ☐Frequent infections

☐Itching ☐Skin ulcers ☐Mouth ulcers ☐Epistaxis

☐Hair/Nail changes (Describe.)

☐Pigmentations (Describe.)

Past Medical History

Past history of similar condition?

Chronic diseases ☐DM ☐HT ☐MI ☐TB ☐RF ☐angina ☐asthma ☐jaundice ☐stroke ☐epilepsy

Hospitalizations?

Past Surgical History

Previous operation? Previous pr ocedures? ☐Angioplasty ☐Endoscopy

Anesthesia ☐Local ☐General ☐Blood transfusions?

Post-operative complications?
 Family History
History of similar illness in the family?

History of ☐HT ☐DM ☐IHD ☐TB

First Degree Relatives:(Age, Health status, mental health, cause of death)

Personal/Social History
☐Smoking status: pack-year?

☐Alcohol type: amount:

☐Home situation? ☐Hobbies?

☐Mobility & help at home? ☐Animals?

☐Water supply Diet

Travel History Sexual History Immunizations?

Occupational History
Nature of the occupation?

For how long?

Anything medically relevant?

Drug History
Drugs Doses Indication Duration Any side-effects

Allergies
☐To Drugs? ☐ To food? ☐ Problems with anesthesia?