1

Personal History
……………………………………………,………months/years old , male/female , from ………………….. & lives in………………….
,referred from / Admitted to hospital on ………… , - - at : pm/am , history taken on …………. ,
- - at : am / pm from patient ……………………………

Chief Complain
Patient complain / suffer of ……………………………………………………………………………………….. , …………. Days / Months
Year before admission.

History Of Present Illness

………..months / years old , male / female patient , was in his / her usual health state .

Known case of …………………………………………………………for……………. Years with adherent / not adherent

to………………………………………………………………….mg ..….*…... OR without any drugs.

Since……….. days / month / year , > 4 yrs. Patient Start complain of …………………………………………………..

< 4 yrs. Patient mother noticed her baby suffered of…………………………

Cough Increase Bowel Motion Vomiting Fever

*Onset *Onset *Projectile / Effortless *Onset
*Course *Course *Related to meal *Course
*Dry / Wet *Frequency *Precede by nausea *Pattern
*Diurnal variation *Amount *Amount *Diurnal Variation
*Interrupted the feeding *Color *Color *Relieving by
*followed by vomiting *Odor *Content *Aggravating by
*followed by cyanosis *Content *Odor *Association with
*associated by -Blood / Mucus *Frequency
- sweeting *Tenses
- Shortening of breath
Swelling Abnormal Movements Pain
*Site *Pre Ictal:  Site
*Onset - Pt Condition  Onset
*Course -Pt Action & position  Course
*Uni / Bi -aura  Character as
*Generalized / Localized *Ictal
 Shifted/Radiated to
*Pain less / full - Tonic / Clonic
- Rolling Of Eye  Aggravated by
*Pitting / Not Pitting  Relieved by
*Mild / Moderate / Sever - Pitting Of Tounge
- Drop Saliva  Associated with
*Aggravated by
*Relieved by - Urination / Defecation
*Associated with - Duration
i.e (Its effect according site) - First aid
*Post Ictal
- Conscious / Confuse
-Sleep / coma

Done by/ Amal Almansoob

 History Of Present Illness 2

Done by/ Amal Almansoob

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Review Of Other System

General Health Nervous System Cardiovascular System

*Well being *Headache *Chest Pain
*Appetite *Dizziness *Breathlessness
)Vertigo/Light headed) -lying flat
-at night
-few exertion
-heavy exertion
*Weight Changes *Faints / Fits *Palpitation
*Change of Sleep *Paraesthesia *Claudication
(Numbness / Tingling) (Leg Pain When Walk)
*Change Of Mood *Weakness *Ankle Swelling
*Visual Disturbance
*Hearing
-Deafness /Tinnitus
*Memory Changes
*Concentration Changes

Respiratory System Gastrointestinal Tract Genitourinary System

*Shortening Of Breath *Oral Ulcer *Change of Urine Color
*Cough *Dental Problem *Dysuria
*Wheeze *Dysphagia *Nocturia
*Sputum Production *Odynophagia *Hematuria
(Color , Amount)
*Hemoptysis *Nausea & Vomiting *Urgency
(Blood On Sputum)
*Chest Pain *Hematemesis *Frequency
(Inspiration Or Coughing) (Vomiting Blood)
*Indigestion *Hesitancy
*Heartburn *Incontinence
*Abdominal Pain *Bleeding
*Change in Bowel habit *Discharge
*Change Stool Color *Dyspareunia

Endocrine System Musculoskeletal System Others

*Heat Intolerance *Joint Pain *Bleeding
-Site - Amount – color
– With clot or not
*Cold Intolerance *Joint Stiffness *Bruising
*Change in Sweating *Joint Swelling *Itching : Site - Severity
*Polydipsia *Change of Mobility *Skin Rash : Site - Describe
*Falls *Discharge (type)-Amount
- Site (ear , nose ,…..)

Done by/ Amal Almansoob

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Pere Natal History (Birth History)
Mother age at conception….…years old , Gravid………Para……..+………, Length of pregnancy was ……… months
with ire / regular Antenatal care, …………history of Preeclampsia , Vaginal Bleeding & infectious Disease during
pregnancy , ……….. history of medical disease such as Diabetes mellitus , Chronic heart disease , Hypertension
& Hepatitis, ………… history of Blood Transfusion , ………. History of exposure to X-ray radiation, ……..
Vaccination, ……….. Special habits for medical important as Chewing Qat, Cigarette Smoking , tobacco etc.

Natal History
Full / Pre term , Normal / Augmented / Induction Vaginal Delivery OR Caesarian Section Due to………………………
, At Home / Hospital , With / Without Complication for mother & baby during delivery , Baby crying
Immediately /After …………………..minute , No need for resuscitation , nursing or incubator care, His / Her
weight was ……………. Kg / unknown .

Post Natal History

…………Cyanosis,…………Jaundice , ………..Pallor, ………….Convulsion , …………Bleeding ,………..Birth injury , Baby
First feeding was…………….hours after birth.

Nutritional History
Baby breast feeding………….times /day, for………….minute duration, Bilaterally , exclusively and satisfaction ,
……….Artificial feeding start in ……………months , due to…………………………………………..by using ………………………..
milk , through mix …………..Spoons of milk/…………ml , ………..times/day , with good sterilization & without
complication , Baby weaning at age………….months, in form of few ……………………………………………………………………
………………………………… , unknown allergy to food.

Developmental History

*Motor: Accepted / not Accepted according his / her age.

.*Social: Accepted / not Accepted according his / her age.

*Speech: Accepted / not Accepted according his / her age.

Vaccination History

Documented / not documented Fully vaccination according to Yemen vaccination program according to
his / her age , without complication.

No Vaccination / ………… times vaccination, 1st on………..month then

on………months,…………………………………… ………………………………………………………………………………………………

Done by/ Amal Almansoob

 Past History 5

.............. Similar Attack

……………. History of chronic & congenital disease

……………. History of hospital admission

…………….. History of infectious disease

…………….. History of Blood transfusion

……………… History of surgical intervention

……………..History of Drug use

Family History
Mother is…………..years old , with good / bad health , No chronic disease or congenital disease & father is
………….. years old , with good / bad health , no chronic or congenital diseases, father &mother has +ve / -ve
Consanguity , No similar condition on family , He /She has………… siblings ,………..yrs. , …………. yrs. ,
…………………………………………………………………………………………..……….. , with good / bad health.

Socioeconomic History
His / Her mother is ………………..education ,her work is…………………….. , ……….. Special habit for medical important
as…………………………………………………………………………………………………………….. , His / Her father is …………………..
education , his work is………………………………………, ………………. Special habit for medical important , there house is
Own / Rent , Contains……………….Rooms ,……………. Kitchen, ………baths, they are…………individual on house ,
every room for………person, it is Bad / Acceptable / Good Ventilation , sewage , water supply. ( poor / moderate
/ rich Socioeconomic state) , ……….. Animal contact as…………………………………………near house / in the first
floor…………………………….. , ……… history of travelling.

General examination
Patient look well / ill , Conscious / confused / coma (with Glasgow coma scale……..) , Calm / lethargic / irritable /
alert ,……… Interested / Oriented , ( > 4yrs. ) intact immediate , remote , recent , …………… memory , on
comfortable …………………….position , under / average / over body built , ………. Sign of respiratory distress ,
…………. Sign of dehydration , (if infant) ……………Sign of increase intra cranial pressure , …….. Pallor , …….
Cyanosis ,…….. gundice, no characteristic face, patient has( O2 …… , Iv line on…………. Hand / leg (……… Gage,
clean / not , good / bad fixation , For………………………) , His / Her pulse ………. Beat / minuet from ……………….. ,
regular / irregular , symmetrical , with average force and volume , present in all other place , His / Her
Respiratory Rate is regular / irregular …………cycle / minuet , Abdominothoracic / thoracoabdomen , His / Her
temperature is ……….. degree Celsius © by oral / axial / rectal , His / her Blood pressure is ………. /……….. mm/Hg
(millimol per mercury) from ………….. hand / leg , On ………………………… position , taken at …….:……. pm/am .

Done by/ Amal Almansoob

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Anthropometric Measurements
Is Used to Assessment of growth and development
This is done by measuring certain aspects of growth (e.g. head circumference, body length and weight ) and comparing them to
anthropometric charts (growth charts or curves).The growth charts are designed with percentile values where values below 5th or above
95th percentiles are abnormal and need evaluation.
In infants, measurements of H.C, length and weight are supplemented by observation of the nutritional state, dentition and size of the
fontanels. In older children, measurements of stature and weight may be supplemented by measurements of body segments (extremities,
span and sitting height). In adolescents, in addition to height and weight, they require assessment of the sex maturity and body fat content

Weight Length ( Height) Head Circumference Mid Arm Circumference

*first week drop 10% Wt Age Average(cm) Age Average HC (cm ) It is midway between
*2 weeks regain birth wt At birth 50 At birth 35 the acromion and
*first 4 mo. ¾ kg/mo. At 1 year 75 At 6 mo. 44 olecranon Processes .
At 2 years 87.5 At 1 yr. 47 It measures the
*2nd 4 mo. ½ kg/month 3-12 yrs. (age (yr.) x 6) +77 At 2 yr. 49 subcutaneous fat and
*last 4 mo. ¼ kg/month. or muscles mass .
2-7 yr.: ½ cm / yr.
*Doubles birth wt 5 mo. (age (yr.) x 5) + 80
*Triples birth wt first year . 8-12 yr.: ⅓ cm / yr. Newborn……………9cm
3mo…………………10cm
*(2-5yr.) (2 kg/yr.)
6mo…………….. 11.5cm
*Early school (3-3.5 kg/yr.)
9mo……………… 12cm
Age Average Wt(kg)
At birth: 3.25 1-5 yrs…13.5-14.5 cm
3-12 mo.: age (mo.) + 9 (Normal)
2 12.5 - 13.5 cm
1-6 years: age (yr.) x 2+8 (moderate malnutrition(
7-12 years: (age (yr.) x 7)-5
2
below 12.5cm
(severe malnutrition)
Chest Circumference Upper/ Lower Segment Surface area of body Fontanels

Age Average(cm) *Birth 1.7 / 1 a. Anterior :

At birth 33 *3mo. 1.65 / 1 Body surface area = Age Average(cm)
1 year 47 *6mo. 1.61 /1 birth 4-5
6 years 58 *9mo. 1.58 / 1 √Height (cm) x Weight (kg) 6mo 3
15 years 78 *1yr. 1.54 / 1 _____________________ M² 1 yr. 1.5
*2yrs. 1.44 / 1 √ 3600 18 mo. closed
*3yrs. 1.33 / 1
*Birth …………….Head > 2cm *4yrs. 1.27 / 1 b. Posterior:
* Until 2 yrs. …..Equal *5yrs. 1.21 / 1 Body Mass Index Normally closed at
* > 2 yrs .….…Chest > Head *7yrs. 1.14 / 1 birth, but may be
*8yrs. 1.1 / 1 opened at birth about
*10yrs. 1/1 Weight (kg) 0.5 cm and usually
1(Vertex – Symphysis pubis) BMI = ---------------- (meters)² closes shortly after birth
2(Symphysis pubis – feet) (Height)² (2-4 mo.).

Teeth Eruption : Muscle mass Notes

Deciduous (20) age Permanent(32) age Muscle mass =
-Central incisors 6th mo. -First molar 6th yrs. mid-arm or mid-leg
-Lateral incisors 9th mo. -Central incisors 6th yrs. circumference - skin fold
thickness.
-First molars 12th mo. -Lateral incisors 7th yrs
• Skin fold thickness:
-Canines 18th mo. -Canines 10th yrs -The skin and subcutaneous fat
-Second molars 24th mo. -First premolar 10th yrs are pinched by especial caliber
-2nd premolars 11th yrs. over the deltoid or sub scapular
-2nd molars 11th - 12thyrs. region.
-Third molar 20th year

Done by/ Amal Almansoob

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Done by/ Amal Almansoob