History Taking Checklist

Date of taking history:

Occupation
Name: Residency: Religion:
ME
Gender:
F Date of Admission:
10 23
Mode of referral: Doctor

µ Age:
52 Marital Status: M 2D s Mode of arrival:
Chief Complaint & Duration:
chestpain for Bd dizzines and near faint
History of the Present illness:
Pain

Site
5 www.wias.D mslwu
again
endoscopy

ifeng.am
Onset
j
HIIIII
Character

Radiation back

ÉFe tent
Duration
crimecourse
Severity

Exacerbating F. exertion

Relieving F. paracetamol

Associated Symptoms

☐ No ☐ Yes, List them

nansia
cough
fever
ROS: 2. Cardiovascular
1.General Chest pain on exertion ☐Dyspnea
h
y
☐Appetite ☐Water intake ☐Sleeping Site ☐Orthopnea

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

I
☐Fever (documented?)

Site: Duration:
Character

Radiation
☐Palpitation (onset? duration? regularity?)
Fusco
☐Edema (site? Pitting or not?)

Onset: Relieving F: paracetamol Duration

x☐Swollen ankles
ginny
Associated Symptoms: Exacerbating f. ☐Intermittent Claudication
my
y
☐Rigors ☐Chills ☐Sweating (Degree?) Relieving f. Additional notes:

Additional notes:
mi 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 wise Exacerbating f. ☐Swelling(R,L)

ox.a
Additional notes: Relieving f. ☐Any change

Tfm't's's
blood
coughing
Associated s.?
in
in color/shape?

4.GIT 5.GU
☐Dysphagia
egtIgnsitfoda myyy
☐Discomfort after eating(indigestion)
Dyspepsia
mm
Color of urine:

frequency:
amount:

blood? Describe.
Fematuria
☐Heartburn site? ☐Urgency ☐Hesitancy ☐Drippling

☐Excessive belching oincontinence

x
☐Nausea with/without ☐Vomiting Men ONLY
Vomitus details: Describe the nature. Color: ☐Blood? ☐Genital rash(Describe)

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

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

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

☐Alternating ☐Incontinence

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

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

Abdominal Pain

Females ONLY
Site
A1 www mn
Onset: coughs
sa Menarche
antedate potpadsused
Character:stabbing Regularity ☐on drugs? Amount:
carat
Radiation: ☐Hot flushes?
a ☐Menopause
m
☐PMB?

Duration: ☐Menstrual pain? (Describe if abnormal) gym

intermittent constant x
Exacerbating f.eating

Relieving f.
restdrinkingfluids ☐Bleeding between periods?
x
Associated Symptoms ☐ (If appropriate) Painful intercourse?
x
☐ No ☐ Yes, List them ☐Pregnant ☐Contraception Method?

II
Additional notes: Type of labor:

No. of children? antiistillbirths

No. of miscarriages?

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

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

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

x
☐Fits? Character:

☐Limb weakness (Describe the site, nature) Duration

Bilateral
unilateral
☐Numbness (Site?) Frequency:
i o
☐Tremors? unsteadiness
Radiation:

☐Concentration problemsInemorsestigt Exacerbating/Relieving f:

x
☐Vision problems
x
☐blurred ☐double vision
Eran
Severity:

☐Hearing problems case

sequent
☐↑
an☐↓ ☐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

9. Hematological
a
☐Neck swelling ☐Polyuria ☐Libido

☐Fine tremor I
☐Fatigue
gym ☐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

Fanfromnose
☐Hair/Nail changes (Describe.)
oswellingLumps
☐Pigmentations (Describe.)

Past Medical History

Past history of similar condition?

Chronic diseases ☐DM ☐HT ☐MI ☐TB ☐RF ☐angina ☐asthma ☐jaundice ☐stroke ☐epilepsy
a w om OcopDiotransientischemicattack
Hospitalizations? og a go me
ImentalHealth
Past Surgical History
ineatietate Panther
Previous operation?
gaspeddeny 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

ya y a e
First Degree Relatives:(Age, Health status, mental health, cause of death)
xxx m

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

☐Alcohol type: amount:

go☐Home situation?pom
Eve
a
4 5 ☐Hobbies?
a
☐Mobility & help at home?
Ha ja ☐Animals?

☐Water supply Diet

i
Travel History Sexual History Immunizations?

syria

Occupational History
Nature of the occupation?

For how long?

Anything medically relevant?

Éj
pain in neck
andshoulderleft
owe
fooverthecounter
Drug History aurgyotangscrenciana
515
Drugs my
Doses Indication Duration Any side-effects

paracetamol
anergesic

Allergies
x
☐To Drugs? ☐ To food? ☐ Problems with anesthesia?
or animals