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HISTORY TAKING & EXAMINATION
Approved by the department of medicine
ALLIED HOSPITAL PUNJAB MEDICAL COLLEGE FAISALABAD.
Note.
Please tick-mark where required.
Explain where essential.
THE HISTORY
Introduction
Name.................................s/d/o...............................
Age.............years Sex......... Marital status..............
Religion............ Occupation.............. Reg. no...........................
Bed no.............
D.O.A.................. D.O.D....................
Address................................................................................................
Via OPD........ , Emergency........, Reference.......
Presenting complaints (In chronological order, in pt's own words)
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History of present illness
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Systemic enquiry (don't repeat same questions)
General
Appetite............Wt.change ............Sleep disturbance
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Energy...... Lethargy........... Fatigue ........ Fever .................
CVS
Chest pain ( ) Compression ( ) Breathlessness( )
Paroxysmal nocturnal dyspnea( ) Orthopnea ( ) Feet swelling ( )
Pain in legs on walking ( )
Respiratory system
Cough ( ) Sputum ( ) Hemoptysis ( )
Breathlessness ( ) Wheeze ( ) Rhinitis ( )
Seasonal variation ( )
GIT
Nausea ( ) Vomiting ( ) Abdominal Pain ( )
Heart burn ( ) Difficulty in swallowing (dysphagia) ( )
Altered bowel habits ( )
Bloody vomiting (haematemesis) ( )
Black tarry stools (malena) ( )
Yellow sclera (jaundice) ( )
Abdominal distension ( )
Urinary System
Pain ( ) Frequency ( ) Urgency while micturation ( ) Haematuria ( )
Anuria ( ) Polyuria ( ) Oliguria ( ) Nocturia ( ) Passage of gravel in urine ( )
Flank pain (nausea vomiting fever) ( ) Burning discharge ( )
Nervous System
Weakness ( ) Numbness ( ) Headache ( ) Vomiting ( ) Giddiness ( )
Blackouts ( ) Fits ( ) Visual loss ( ) Diplopia ( ) Vertigo ( )
Altered conscious level ( ) Irrelevant talk ( )
Locomotor System
Joint pain ( ) Stiffness ( ) Swelling ( )
Restriction of movements ( )
Skin
Rash ( ) Itch ( ) Pigmentation ( )
Ulcers ( ) Patchy hair loss ( )
Hematology
Purpuric rash ( ) Bleeding gums ( ) Leg ulcers ( )
Endocrinology
Polyuria ( ) Polyphagia ( ) Polydypsia ( ) Sweating ( )
Heat ( )\Cold ( ) Intolerance ( ) Wt.gain ( ) \ Loss ( )
Palpitations ( )
Explain for any symptom found in the systemic review.......
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Third party information (Ideally from a relative living with the
pt. )
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Past History
Previous hospitalization ( ) Similar disease in the past ( )
TB ( ) Hepatitis ( ) Asthma ( ) Arthritis ( ) Jaundice ( ) DM ( )
H/O blood transfusion ( )
Detail if relevant
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Personal History
Pt's socioeconomic status ................
Dietary habits ................
Drug addiction ................
Smoking active/passive ................
Health of wife /husband/children ................
H/O foreign travel ................
Immunization ................
Allergy to anything ................
Occupational History (Present & In the past)
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Family History
Similar disease in the family ( dm ( ihd ( htn ( Hepatitis ( Arthritis ( Stroke
( tb ( Malignancy ( Deaths at early ages in
the family (
Menstrual History
Age at menarche......... Length of cycle.......... Frequency...........
Regularity ( )
Pain associated with menstruation ( Dysmenorrhea) ( )
Pain during coitus (Dyspareunia) ( ) Age at menopause............
Postmenopausal symptoms--- Hot flashes ( ) Postmenopausal bleeding ( ) /
Discharge ( )
Treatment/ Drug History (if indicated)
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