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History Taking Checklist.

This document provides a checklist for taking a patient's medical history. It includes sections to record the patient's name, gender, age, occupation, residence, chief complaint, history of present illness, review of major body systems, past medical history, past surgical history, family history, drug history, personal and social history, and occupational history. The checklist is comprehensive in nature and aims to gather all relevant health-related information from a patient in an organized manner.

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لو ترى
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283 views4 pages

History Taking Checklist.

This document provides a checklist for taking a patient's medical history. It includes sections to record the patient's name, gender, age, occupation, residence, chief complaint, history of present illness, review of major body systems, past medical history, past surgical history, family history, drug history, personal and social history, and occupational history. The checklist is comprehensive in nature and aims to gather all relevant health-related information from a patient in an organized manner.

Uploaded by

لو ترى
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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History Taking Checklist

Name Religion
Gender Blood group
Age Date of admission
Occupation Date of taking history
Residency Source of referral
Marital status Mode of arrival

Chief complaint and Duration:

History of Present illness:

DR. ABDULLAH SABAH OMRAN


REVIEW OF SYSTEM
GENERAL Cardiovascular system Respiratory system
appetite Chest pain Chest pain
weight loss/ gain dyspnea dyspnea
Daily activity orthopnea apnea
Night sleep Paraoxysmal cough
mood nocturnal dyspnea Sputum
fever palpitation wheeze
chills Syncope/faint cough
Rigors Leg edema hemoptysis
sweating Intermittent Hoarseness of
claudication voice
Additional note
Additional note cyanosis
Additional note

Gastrointestinal system Genito-urinary system Nervous system


Abdominal pain dysuria headache
Abdominal distension hematuria Dizziness
dysphagia polyuria vertigo
odynophagia oliguria unsteadiness
Nausea & vomiting annuria Consciousness
Jaundice Enuresis Seizure
dyspepsia Frequency syncope
diarrhea nocturia Vision blurred/
constipation urgency diplopia
tenesmus Urinary incontinence Hearing tinnitus
melena hesitancy Dysarthria
hematemesis drippling numbness
Hematochezia Loin pain Limb weakness
Additional note Urinary retention Changes of
Edema behavior
Concentration
Genital rash
memory
Urethral discharge
Additional note
Vaginal
pain/discharge

DR. ABDULLAH SABAH OMRAN


Musculoskeletal Menstrual & obstetric Endocrine
arthralgia Menarche Heat intolerance
myalgia menapause Cold intolerance
Difficulty moving regularity fatigue
stiffness Amount tremor
Joint swelling dysmenorrhoea Neck swelling
Frequent fractures Inter-menstrual Polydipsia
Back/neck pain bleeding polyuria
Sore eyes Post-menopausal hirsutism
Dry mouth bleeding loss of libido
weakness contraception Erectile dysfunction
pregnancy Additional note
G
p
A

Hematological Mucocutaneous
bleeding spots Hair loss
bruises Skin rash
Frequent infection itchying
lumps skin ulcers
Additional note Mouth ulcers
pigmentation
nail changes
hair changes
epistaxis

Additional notes:

DR. ABDULLAH SABAH OMRAN


Past medical history Past surgical history Family history
hypertension o Name of operation • History of similar illness:
diabetes
Hyper- o Cause of operation
cholesterolemia
asthma • History of genetic diseases:
epilepsy o Date of operation
Ischemic heart
disease
o Type of anaesthesia • History of :
Heart failure
(general/ local) HTN
Stroke/ TIA
DM
Bleeding
tendency IHD
o Post-op complications
Chronic renal TB
diseases Asthma
TB o Blood transfusion Others
Blood transfusion
Previous
hospitalization o Anaesthetic problems

Drug history Personal & social history • First degree relative:


• Name of the drug § Smoking (pack-year) age
State of
health
• Dose § Alcohol (type-amount) Cause
of death

• Route of administration
§ Home situation
Occupational history
• Duration & frequency
§ Water supply
§ Nature of work

• Side effect
§ Recent travels
§ Duration

• Drug allergy (name and type of


§ Domestic animals
allergy) § Any occupational symptoms

§ Sexual history
• Food allergy

DR. ABDULLAH SABAH OMRAN

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