History Taking

Patient Biodata:
1. Name(Triple):
2. Age: Years old
3. Sex(Gender): Male Famle Bisexual
4. Marital status: Single Married Widow Divorced
5. Religion: Muslim Christian Yazidian Sabian
6. Occupation(Job):
7. Residence(Address):
8. Date of admission: / /
9. Date of examination: / /

Chief Complaint and Its Duration:

(One or two no more!)

History of Present Illness(SOCRATES):

1. Site:

2. Onset: Sudden Gradual

3. Character(Nature): Aching Burning Stabbing Constricting Stitch

(Preferably using the patient’s own word description rather than offering suggestion)
4. Radiation:

5. Association phenomena:

6. Time (special time of pain occurrence or all the time):

7. Exacerbation and reliving factors:

8. Severity: Mild Moderate Severe

*In some cases like fever: don’t ask about site, character, radiation, exacerbation and reliving factors,
Instead: ask about treatment and response to it.
‫ ابراهمي محمد سلطان‬:‫اعداد الطالب‬
Review of Other System:
 Cardiovascular System(CVS):
Shortness of breath(Dyspnea):
1. Chest pain (usually center):
Shortness of breath when lying flat
2. Shortness of breath(Dyspnea):
(Orthopnea):
Sudden shortness of breath during
3. Awareness of heart beat(Palpitation):
sleep (PND Paroxysmal Nocturnal
4. Brief loss of consciousness (Syncope): Dyspnea):
5. Calf muscle pain(Claudication):
6. Peripheral swelling(Edema):

 Respiratory System:
1. Chest pain (usually lateral):
2. Shortness of breath(Dyspnea):
3. Cough: Dry: Productive:
4. Sputum: Amount: Color:
5. Noisy breathing (Wheezing, Stridor):
6. Coughing of blood (Hemoptysis): Amount:

 Gastrointestinal Track(GIT)
1. Appetite: loss (Anorexia): Good:
2. Weight: loss: Gain:
3. Swallowing: Good: Difficulty (Dysphagia or Odynophagia):
4. Abdominal pain:
5. Flatulence:
6. Indigestion (Dyspepsia):
7. Heartburn (burn sensation in the stomach or chest area):
8. Nausea:
9. Vomiting: Amount: Color:
10.Vomiting of blood (Hematemesis): Amount:
11.Bowel motion: Frequency: Amount: Color: Consistency:
12. Stool abnormality:

* From bowel motion we will know if it diarrhea or constipation.

Abnormal evacuation in general: 3 times per day(Diarrhea), less than 3 times per week(Constipation).
 Genitourinary System (GUS):

1. Loin pain:
2. Difficulty of urination/pain passing urine (Dysuria):
3. Frequency and time, passing urine (at night Nocturia):
4. Quantity of urine: Normal: Polyuria: Oliguria: Anuria:
5. Color of urine (blood in urine (Hematuria)):
6. Sudden need to pass urine (Urgency):
7. Inability to prevent discharge of urine (urine Incontinence):
8. Dripping:
9. Ureteral discharge (Men): Amount: Color:
10. Vaginal discharge (Women): Amount: Color:
11. Vaginal bleeding: Amount:
12. Last menstrual period (consider pregnancy): Regular: Length:

 Nervous System(CNS):
1. Headache:
2. Dizziness:
3. Sensation of unsteadiness (Vertigo):
4. Temporarily loss of consciousness (Faints):
5. Abnormal movement:
6. Altered feeling: Depression: Confusion: Anxious:
7. Weakness: Facial: Limb:
8. Abnormal sensation: Numbness: Tingling:
9. Visual disturbance:
10. Hearing problems (Deafness, Tinnitus):
11. Memory and concentration changes:
12.Sleep disorder:

 Locomotor System:
1. Muscle: pain: Weakness: Contract:
2. Bone: pain:
3. Joint: pain: Swelling: v Stiffness:

 Skin System: Rash: Ulcer: Sweating: Itch: Lumps:

  Past Medical History:
1. Similar condition in the past:
2. History of endemic disease: T.B: Malaria:
3. History of common disease: DM.: HP: Rheumatic Fever:
Jaundice: Hypercholesterolemia: Angina: MI:
Asthma: Epilepsy: Stroke or TIA:
4. Previous admission to the hospital:

*If past disease present ask about:

When was it diagnosed?
How has it been treated?

 Past Surgical History:

1. History of any operation or injury:
Operation: Date: / / Type: Any complication:
2. History of trauma: head: Chest: Abdomen:

 Drug History:
Name: Dose: Duration: Mode of Use:
1.
2.
3.
Drug allergy (Especially Penicillin, Methoprime, Sulfa group):

 Family History:
1. Similar condition in the family:
2. Family history of common disease:
3. Premature death of member of the family: Age: Cause:

 Social History:
A) Personal History: Single: Married: No. of Children:
Occupation: Hobbies: Habit: Alcohol:
Smoke: Light: Heavy: {Less than 20 Cigarette Light Smoker, >20 heavy}
B) Social History:
Economic status: Good: Mild: Moderate:
House: Type: Size: Owned: Rented:
Animal in the house: Travel aboard: