A) HISTORY
1. General Information:
Name:
Age/Gender:
Address:
Source of history: Patient/Relative/Carer
2. Chief complaints:
Complaint X Duration
Chronological order
Maximum 4-5
Should include all major symptoms (important for making hypothesis)
Duration should be specific rather than time interval (e.g. 10 days instead of
1-2 weeks)
Chief complaints can be included in retrospect
Example:
Lower abdominal pain X 2 days
Nausea and vomiting X 1 day
3. History of Presenting Illness:
“OPQRST” for each symptoms
Onset (acute, insidious, chronic)
Provocative/Palliative and Progression
Quality and/or Quantity
Region and Radiation
Severity
Timing and Temporal relationships
Others:
Duration and Frequency
Any diurnal variation
Associated symptoms
Last meal and Tetanus status
Negative history:
Red-flag symptoms
Ruling out differentials
Probable etiology
Severity and complications
Treatment received for the complaint
Review of systems: may or may not be related to chief complaint – include only
positive finding
Add for females
Menstrual and Obstetric History:
• LMP
• Duration of flow/Cycle Length
• Clots passage, Average number of pads soaked, Dysmenorrhea
• GxPxAxLx – mode, indication and time
• Contraceptives
Add for pediatric patients
• Birth history
Any antenatal/natal/postnatal complications
