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Name Age Gender Residency Occupation Marital Status Blood group Religion Date of admission Date of taking history Source of referral Mode of arrival Designed & Printed by Med.printt Identity: History of present illness: Chief complaint and duration: 1
appetite Weight loss Daily sleep Night sleep Mood Fever chills Rigors Sweating Respirator y System Cardiovascular System headache Dizziness vertigo unsteadiness Consciousness Seizure syncope Vision blurred/ diplopia Hearing tinnitus Dysarthria numbness Limb weakness Changes of behavior Concentration memory Abdominal pain Abdominal distension dysphagia odynophagia Nausea & vomiting Jaundice dyspepsia diarrhea constipation tenesmus melena hematemesis Hematochezia Chest pain dyspnea apnea cough sputum wheeze hemoptysis Hoarseness of voice cyanosis dysuria hematuria polyuria oliguria annuria Frequency nocturia urgency Urinary incontinence hesitancy drippling Loin pain Urinary retention Edema Genital rash Urethral discharge Vaginal pain/discharge Chest pain dyspnea Palpitation Syncope / faint Leg edema Paroxysmal nocturnal dyspnea Intermittent claudication Orthopnea Designed & Printed by Med.printt 2 REVIEW OF SYSTEM GENERAL GIT UTI Nervous system Additional note:
Hair loss Skin rash itchying skin ulcers Mouth ulcers pigmentation nail changes hair changes epistaxis arthralgia myalgia Difficulty moving stiffness Joint swelling Frequent fractures Back/neck pain Sore eyes Dry mouth weakness Menarche menapause regularity Amount dysmenorrhoea Inter-menstrual bleeding Post-menopausal bleeding contraception pregnancy G P A bleeding spots bruises Frequent infection lumps Heat intolerance Cold intolerance fatigue tremor Neck swelling Polydipsia polyuria hirsutism loss of libido Erectile dysfunction Designed & Printed by Med.printt 3 REVIEW OF SYSTEM Mucocutaneous Musculoskeletal Hematological Menstrual & obstetric Endocrine Additional note:
hypertension diabetes Hyper cholesterolemia asthma epilepsy Ischemic heart disease Heart failure Stroke/ TIA Bleeding tendency Chronic renal diseases TB Blood transfusion Previous hospitalization Name of the drug Dose Route of administration Duration & frequency Side effect Drug allergy (name and type of allergy) Food allergy Designed & Printed by Med.printt Medical • Surgical • Family • Social • Drug History Anaesthetic problems Date of operation Cause of operation Name of operation Type of anaesthesia (general/ local) Post-op complications Blood transfusion 4 COMPREHENSIVE PATIENT HISTORY Past m edical history Past surgical history Drug History
HTN DM IHD TB Asthma Others Smoking (pack-year) Alcohol (type- amount) Home situation Water supply Recent travels Domestic animals Sexual history History of similar illness: History of genetic diseases: age State of health Cause of death Designed & Printed by Med.printt Medical • Surgical • Family • Social • Drug History Family history Personal & social history 5 COMPREHENSIVE PATIENT HISTORY History of : First degree relative:
Oral intake Tubes & Drains Treatment received Name & reason of the operation Time of admission to operating theater Type of anesthesia Blood transfusion Known complications Time of discharge from operating theater Time of regaining consciousness Any other relevant information Cough/sputum Pain inthe legs Dyspnea Mobility Fever Chest pain Nausea and vomiting Pain at site of operation Passage of urine Passage of flatus or stool Wounddischargeorbleeding Designed & Printed by Med.printt 6 Surgical 1. Brief pre operative history 2. Operative history 3. Postoperative history Operative history Postoperative history Steps in HPI:
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