Personal Data
Name: Age: Nationality: Gender:
Admission: Hospital file number :
Chief Complaint + Duration :
History of Presenting Illness
Site: Progression:
Onset: Nature:
Course: Radiation:
Aggravating F: Frequency:
Relieving F :
Associated symptoms:
Fever. Chills. night sweating . fatigue. Anorexia. Weight loss.
Others:
Menstruation (regularity, duration):
System Review
(don’t forget to ask about the following)
CVS RS GI CNS US ENDO MSS
Chest pain Chest pain appetite Headache Loin pain Polyuria Anemia
Dyspnea Dyspnea nausea Seizures Dysuria Plydipsia Weakness
Orthopnoea Cough vomiting Dizziness Polyuria Wt. loss Jaundice
Palpitations sputum hematemesis Tremor oligouria Sweating Fatigue
Cyanosis Wheezing dysphagia Weakness Hematuria Hair Bruising
PND Stridor odynophagia Numbness Nocturia distribution Bleeding
Syncope hemoptysis Heart burn Paralysis Incontinence Nocturia LN
Intermittent Sore throat distention Abn. Move. Frequency Neck swell enlargement
claudication Runny nose Abd. pain Hearing loss Urine color Amenorrhea Dyspnea
LL edema jaundice Blur vision Hesitancy Pigmentation Bone pain
diarrhea Abn. Speech Urgency Galactorrhea Wt. loss
steatorrhea Smell Discharge Heat Rash
constipation Taste Urine stream intolerance dizziness
Melena Sensation Cold
Hematochezia Neck pain intolerance
Color of stool Facial pain
Abn. gait
NOTE:
Name: Age: Nationality: Gender:
Admission: Hospital file number :
Chief Complaint + Duration :
History of Presenting Illness
Site: Progression:
Onset: Nature:
Course: Radiation:
Aggravating F: Frequency:
Relieving F :
Associated symptoms:
Fever. Chills. night sweating . fatigue. Anorexia. Weight loss.
Others:
Menstruation (regularity, duration):
System Review
(don’t forget to ask about the following)
CVS RS GI CNS US ENDO MSS
Chest pain Chest pain appetite Headache Loin pain Polyuria Anemia
Dyspnea Dyspnea nausea Seizures Dysuria Plydipsia Weakness
Orthopnoea Cough vomiting Dizziness Polyuria Wt. loss Jaundice
Palpitations sputum hematemesis Tremor oligouria Sweating Fatigue
Cyanosis Wheezing dysphagia Weakness Hematuria Hair Bruising
PND Stridor odynophagia Numbness Nocturia distribution Bleeding
Syncope hemoptysis Heart burn Paralysis Incontinence Nocturia LN
Intermittent Sore throat distention Abn. Move. Frequency Neck swell enlargement
claudication Runny nose Abd. pain Hearing loss Urine color Amenorrhea Dyspnea
LL edema jaundice Blur vision Hesitancy Pigmentation Bone pain
diarrhea Abn. Speech Urgency Galactorrhea Wt. loss
steatorrhea Smell Discharge Heat Rash
constipation Taste Urine stream intolerance dizziness
Melena Sensation Cold
Hematochezia Neck pain intolerance
Color of stool Facial pain
Abn. gait
NOTE:
