History taking
Personal data
Name : ....................................................................................Age:.................... Sex:...............Occupation:...............................
Marital status :................. Residence:.................................. Handness:..........................date of administration:..../.../.............
Habits of medical importance: Smoking ........ Alcohol ........... Others..................................................................................
............................................ .................................................................................................................................................
Cheif compliant
.................................................................................................................................Since.........................before administration
History of present illness
Site ......................................Onset:..............................Course........................................Duration..........................
Character:................................., Radiation:.................................................................................................................
Increased by .............................................................Decreased by ..................................................................................
Another related symptoms:.:........................................................................................................................................................
Previous treatment and investigation :...............................................................................................................................
Special question :..........................................................................................................................................................................
Amount:............................, Content :............................., Colour:.........................., ...odor:.....................
Systemic review
CVS CNS Respiratory GUT Rheumatology GIT
Chest pain Headache Chest pain Lion pain Joint pain Nausea
Orthopnea Facial pain Dyspnea Frequency Skin Rash Vomiting
PND Neck stiffness Cough Dysuria Bone pain Diarrhea
Palpitation Weakness Sore throat Incomp.emptying Back pain Constipation
Dyspnea LOC Sputum Urine retention Mouth ulcers Dark stool
Cyanosis Dizziness Wheezing Frothy urine Photosensitivity Pale stool
Ankle swelling Seizure Runny nose Change in colour Weakness Abdominal pain
Speach prob. of urine Odynophagia
Tremor Hemoptysis Distention
Intermittent Swallowing Hoarseness Change in Lower /upper
claudication disturbance amount of urine GIT bleeding
Syncope Visual Heartburn
symptoms Regurgitation
Easy Auditory Dysphagia
fatigability symptoms Juandice
Past history
Do you have chronic Yes HTN ........ , DM..........Under control or not? Yes/No
dis? No
Do you have another Yes What is it?...........................When it started?.......................Under control ? Yes/No
dis? No
Past surgical operation
Yes /No Type Why When Where Complications
Drug history
Yes /No Drugs For (dis) Route Dose Frequency Duration
Asem almeerabi
Blood transfusion
Yes /No When Why How many unite? Any complications?
Allergy history: Yes / No:..............................................................................................................................................................................................................
Family history
Is there Same dis in family,? Yes/No , Age .....................Duration ............................Complications:....................................
Are your partner alive Yes/No Mention age and cause of death ..............................................................................
Any chronic dis? Yes/No What is.?....................................................complications:.........................................
