- Introductory information
- Presenting complaint
- History of presenting complaint
- Past medical, surgical history
- Gynecological history
- Family history
- Social, personal history
- Drug history
- Systems review
- Introduce, shake hands.
- Name, What age are you now [name clues: ethnicity or age-specific dz].
- Where from [if relevant].
- What is the problem lately. Alternatively: What is the problem that brought you to hospital [record in pt's own words].
- Site: where, local/ diffuse, "Show me where it is worst".
- Onset: rapid/ gradual, pattern, worse/ better, what did when symptom began.
- Character: vertigo/ lightheaded, pain: sharp/ dull/ stab/ burn/ cramp/ crushing.
- Radiation [usually just if pain].
- Alleviating factors, "What do you do after it comes on?"
- Time course: when last felt well, chronic: why came now.
- Exacerbating factors, "What are you doing when it comes on?".
- Severity: scale of 1-10.
- Associated symptoms.
- Impact of symptoms on life: "Does it interrupt your life".
- "Were you referred here by your GP, or did you come in through casualty?"
- Past illnesses, operations.
- Childhood illness, obs/gyn.
- Tests and treatment prescribed for these.
• Drugs remaining relevant: corticosteroids, OCP, anti-HTN, chemotherapy, radiotherapy.
- Checklist of dz's:
HTN ["Anyone told you, you have high BP?"]
- Problems with the anesthetic in surgery.
- Time of menarche, if periods regular, menopause.
- Possibility of pregnant, number of children, number of miscarriages.
- Length of cycles, length of period, first day of your last period.
- The current complaint in parents/ siblings: health, cause of death, age of onset, age of death [eg: heart dz, bowel CA, breast CA].
- Health of parents/ siblings/ children: "Are your parents still alive?" "How is the health of your..."
- Hereditary dz suspected: do a family tree.
- Birthplace, residence.
- Race and migration [if relevant].
- Present occupation [and what do they do there], level of education.
• Any others at workplace with same complaint.
- Social habits [if relevant].
- Smoking: "Ever smoked, how many per day, for how long, type [cigarette, pipe, chew]".
- Alcohol: do you drink. If yes: type, how much, how often.
- Travel: where, how lived when there, immunization/ prophylactic status when went [if relevant].
- Marital status [and quality], health of spouse/ children, sex activity [discretely, if relevant].
- Other household members, pets [if infections/ allergies], social support, whether patient can manage at home: "Who's with you there at home".
- Diet, physical activity.
- Community care: home help, meals on wheels.
- "Is there some things that worry you about the symptoms you are having?"
- Prescriptions currently on [don't trust their written doses, do your own when re-prescribe].
- Supplements, HRT.
- Alternative medications.
- Recreational drugs.
- Allergies: drugs [and what was reaction], dyes. Pt. often will confuse side effect with a reaction.
- See Systems Review.