Medical History Checklist.pdfghggjhjhkjkuku

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1. Address:
Blood Group:
Occupation:
Gender:
Date of Taking History:
History of Present Illness (HPI)
Patient Information
History is taking from:
Name: Age:
Note:
medical history checklist
Marital Status: ( ) Boys , ( ) Girls
Date of Admission:
Mode of Arrival: Mode of Referral:
Chief Complaint and Duration (CC)
*Pain characters (SOCRATES)
by Ahmed Thamer
only if significance only if significance

2. Systems Review
1 General
2 CVS
( ) Chest pain
( ) Dyspnea / SOB
( ) Orthopnea
( ) PND
( ) Palpitation
( ) Edema
( ) Swollen ankles
( ) Exercise tolerance
( ) Appetite state
( ) Weight loss or Weight gain
( ) Fever
( ) Sweating
( ) Rigors / Chills
( ) Sleep
( ) Mood
Respiratory
( ) Chest pain
( ) Dyspnea / SOB
( ) Wheeze / Stridor
( ) Cough
( ) Sputum
( ) Heamoptysis
3

3. 4 GIT
( ) Abdominal Pain
( ) Dysphagia
( ) Nausea
( ) Vomiting
( ) Hematemesis
( ) Dyspepsia / Heartburn
( ) Diarrhea
( ) Constipation
( ) *Melena*
( ) Rectal bleeding
5 GU
( ) Frequency
( ) Color
( ) Amount
( ) Dysuria
( ) Polyuria
( ) Oliguria
( ) Anuria
( ) Haematuria
( ) Nocturia
( ) Urgency
( ) Genital rashes / lumps
( ) Urethral discharge
( ) Prostatic problem
( ) Vaginal pain
( ) Vaginal discharge
( ) Hot flushes

4. 6 CNS
( ) Headache
( ) Fits
( ) Coma
( ) Faints
( ) Dizziness
( ) Limb weakness
( ) Numbness
( ) Tremors
( ) Loss of balance
( ) Vision
( ) Hearing
( ) Smelling
( ) Tasting
( ) Difficulty in speech
Musculoskeletal
( ) Arthalgia
( ) Joint stiffness
( ) Joint swelling
( ) Erythema / Warmth
( ) Difficulty in moving
( ) Myalgia
( ) Frequent fractures
( ) Dry mouth
( ) Sore eyes
7
( ) Abortions / Stillbirths
( ) Contraception
Menstrual & Obstetrical8
( ) Menstual cycle
( ) Menopause
( ) Pregnancy

5. 10 Hematological
( ) Bruise easily
( ) Bleed excessively
( ) Bleeding spots
( ) Lumps
( ) Frequent infections
9 Endocrine
( ) Heat intolerance
( ) Cold intolerance
( ) Neck swelling
( ) Fine tremor
( ) Polydipsia
( ) Polyuria
( ) Fatigue
( ) Libido
11 Mucocutaneous
( ) Hair changes / loss
( ) Skin rash
( ) Skin / Mouth ulcers
( ) Itching
( ) Nail changes
( ) Epistaxis
( ) Pigmentations

6. Past Medical History
( ) Diabetes
( ) Hypertension
( ) Heart disease
( ) Jaundice
( ) Stroke
( ) Epilepsy
( ) Tuberculosis
( ) Rheumatism
( ) Asthma
( ) Similar present condition in the past?
( ) Previous hospitalization?
Drug History & Allergies
( ) Contraceptives
( ) Anticoagulants
( ) Herbs
( ) Drug abuse
( ) Anesthesia problem
( ) Allergy to Drug or food
Drug Dose Indication Duration S.E

7. Past Surgical History
( ) Anesthesia [ Local or General ]
( ) Previous Operations?
( ) Post-operative complications?
( ) Blood transfusion
Family History
( ) Family history of genetic diseases? [ HT, DM, IHD, Cancer, ... ]
( ) History of similar condition in the family?
First degree relatives
[ Age, Health status, Mental health, Cause of death ] :
Personal & Social History
( ) Alcohol
( ) Smoking state
( ) Vaccination
Home situation?
[ Airway, Rooms, Family members count, Animals ]
Water supply? Daily diet?
Mobility, Hobbies, Sexual history, Recently traveled
by Ahmed Thamer
only if significance
only if significance
Family income?