History Taking

In easy way

Bio Data

Name Age Gender o Male o Female Nationality

Occupation Marital status How many child you have Residency

Route of admission o ER o OPD o Referral …………………… Date of admission Day: ………………… ( \ \ )

Chief Complaint, And it's duration

……………………………………………………………………………………………………………………………………… Since ………………………… before the admission

History of Presenting Illness (HPI)

Site Onset o Sudden o Gradual Character Radiation

COURSE o Continuous o Intermittent

Alleviating ………………………………………………………………………

Timing PATTERN o Progressive o Constant o Regressive

factors ………………………………………………………………………

Daily and postural variations

Scoring 1 – 2 – 3 – 4 – 5 – 6 – 7 – 8 – 9 - 10
Exacerbating ………………………………………………………………………

Severity

factors ……………………………………………………………………… Interfering with o Daily activities \ o Sleep

Q …………………………………………………………………………………………………………………………………………………………………………………………

Special Qs Substance Amount Color

Qs Content Oder

Associated Symptoms

Ask about the symptoms related to the same system of Chief Complaint, or to possible DDx.

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Risk Factors

Ask about o Smoking, o HTN, o DM, o Hyperlipidemia, o Using the OCP, o Family Hx. of premature ACS, o Hx. of IHD

Other Risk factors related to CC., or to possible DDx. …………………………………………………………………………………………………………………

Constitutional Symptoms

NWAFF Night sweating Weight Change Appetite Change Fever Fatigue

Systemic Review

CVS CNS Respiratory Rheumatology GIT GUT

Chest Pain Headache Chest Pain Joint Pain Jaundice Loin Pain

Orthopnea facial pain Dyspnea Skin rash Dysphagia Change in the

PND Neck stiffness Cough Bone Pain Odynophagia amount of

Palpitations swallowing Sore Throat Back Pain Nausea urine.

Dyspnea disturbance Sputum Mouth ulcers Vomiting

Change in

Cyanosis weakness Wheezing Photosensivity Diarrhea

color of urine.

Ankle Swelling LOC Runny nose weakness Constipation

Intermittent Dizziness Hemoptysis Dark urine Frequency

claudication Seizure Hoarseness pale stool Dysuria

Abdominal Pain Incomplete

Syncope Visual symptoms

or Distention emptying

Easy Auditory Lower\Upper Urine

…

Fatigability symptoms GI bleeding retention

Speech problems Heartburn or Frothy Urine

Tremor regurgitation …

History Taking
1 In easy way

Past medical Hx. (PMH)

previous similar How many times ? Time between each one ?
Yes
attacks? Time of each one? When the last one is happened ?

Did you have any Yes o HTN, o DM, o……………………………… Under control or not ?
chronic Disease ? No -
Did you have any Yes What is it? When it started? under control? Yes No
other disease ? No -
Did you have any Hx. Yes Why? Duration? Inv.
of Hospitalization ? No -
Hx. of Vaccination ? Hx. of Trauma ?
Past surgical Hx. (PSH)

Any previous Surgery? Type Why When Where Complications?

Past drug Hx. (PDH).

Drug For (the dis.) Route Dose Frequency Duration

o Antibiotics o OCP o NSAIDs o CCB o ACEi o ………………… Side effect ? ……………………………………………………………………

Allergy
Yes For what What is the symptoms of reaction? How does it relive?
No Say "No Known Allergy" ( NKA )
Blood transfusion
when Why How many units? Any complication?
Menstrual Hx. in FEMALE pt.
Regular Yes \ NO LMP Duration Amount Age of menarche Age of menopause
Family Hx.
Same disease in your family ? Age of pt. Duration Complications

Are your parents alive ? Yes No Mention the Age and Cause of death ……………………………………………………………………………………
Any chronic dis.? What is it? Complications
Any inherited dis.?
Social Hx.
Type Daily amount Duration Illegal sexual contact ? Where?
Smoking Socioeconomic status ?

Alcohol abuse Floor NO. ? Life with who ?

Q) ………………………………………………………………………………………………
Travel Hx.
Where? When? How long ? Hx. of immobilization ? Yes \ No

Summary
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