History Tacking
GOOD HISTORY=GOOD DOCTOR
1.Name..
2.Age 3.Sex.
4.Occupation.
5.Marital State: Singl
Divorcid Marrid Widow
No.of children Duration
Age of Oldest Age of youngest:
6.Residence:
7. Special Habits:
Smoking Type: Ciggarite Water pipe
Amount.. duration
If stopped ? Why?...............................................................................................................................
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Excessive : Tea coffee ..Cup / day
Qut chewer:..hour/day
8.D.O.A:..
9.Through : ER Reffered Electivily
Chief Complaint The pationt is complaining of
Since.
Chaif complaint
Personal History
Chronic disease:
D.M HTN TB Asthma peptic ulcer
Rheumatic arthritis cardiac problem skin disease
Duration..
Manifested by
.
Investigation by..
.
Treated by
.
Complicated by
Surgical Operations
*Type.. *DATE.
*Site.. * blood trasfusion
Amount
Why
.
Past History
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1.Analysis of complaint
2.Symptoms of the related system
3.Investigation &
treatment(related disease)
History of present Illness
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1.Date of menarch and menopause
2.Frequency of period3. Regularity
4.Duration. 5.Amount of blood
6.History of intake of contraceptive pills......................................................................
*House: rental own
*Ventilation: good moderate
bad
*Water supply: good moderate
bad
*Electricity: good moderate bad
*Animal contact:..
Menstural and Obtetric History
Socio-economic History
Resp
iratory
Sy
stem
Dyspnea Tachypnea Bradypnea Wheezing
Cough ) ( Sputum Chest pain Hemoptysis
Last chest X-ray Asthma Tuberculosis Bronchitis
CVS Heart troubles Hypertension Rheumatic fever Heart murmur
Chest pain Palpitation Paroxysmal nocturnal
dyspnea (PND) Edema
Past ECG Past vascular clots GIT &
HBS
Troubles of swallowing Heartburn Appetite Nausea
Vomiting Bowel troubles Constipation Hemorrhoids Diarrhea Abdominal pain
Jaundice Hepatitis Liver troubles Gallbladder troubles
Stools (color & quantity)
Itchy rashes
Urog
enita
l System
Loins pain Polyuria Urgency Nocturia
Oliguria Anuria Color of urine Burning urination
Hematuria Urinary infections Renal stones Incontinence
Hesitancy Dribbling Hernias Genitalia pains
Menarche (F) regularity of periods (F)
Bleeding frequency (F) Amount of bleeding (F) Last menstrual (F) Dysmenorrhea (F)
Vaginal discharge (F) Abortions (F) ] [ Deliveries No. & Type
(F) ( 54)< Menopause age (F)
Mu
sculosk
eleta
l System
Muscles or joints pain Stiffness Arthritis Gout
Backache Muscle Weakness Movements limitations Hx trauma
Bone fractures Muscles cutting Neurologic
System
Fainting \ Blackouts Seizures Numbness
Loss of sensation Tingling Tremors Involuntary
movements
Hematology Anemia ) ( Hemophilia
Past transfusion Transfusion reactions Endocrine Heat ntolerance Cold intolerance
Excessive hunger Excessive sweating Change in extremities
sizes Excessive thirst
: Group D
Systemic Review