General sheet / Information Gathering
Hello Mr. …. Sit down please. I am …(position)…
Personal history Name – Age – Occupation
History of present complaint Analysis
Other symptoms Relation to the main complaint
What is the problem? ….
Tell me more about that.
Tell me more about …. What about ….? Do you have ….?
History of present investigations and treatment
Systematic direct questions
I’m now going to ask you a series of questions about common medical problems.
This to make sure we do not mess anything that may be important.
Do you have any trouble with your heart, chest pain or palpitation?
Do you have any trouble with your lungs, shortness of breath, coughing or sputum?
Do you have problem in digestion, lose weight, difficulty in swallowing, heart burn, nausea/vomiting, abdominal pain, swelling, change of bowel habits, rectal bleeding?
Do you have any problems passing urine, change of color, pain, smell?
- Diabetes Mellitus
Do you have problems in menstruation?
Have you been admitted to any hospital before?
Did you have any operation before?
Do you have children? How many? How old is the youngest? (Female)
Do you take any medication or contraceptive pills (Female)?
Do you have any allergy?
Do you have any similar problem in your family (children, parents, brothers, sisters)?
Does anyone of your family have a heart disease, DM, blood pressure, tumor or any chronic disease?
Do you smoke? That do you smoke? How much? For how long?
Do you drink? How much/week?
Are you concerned about anything?
To summarise …. (+ve. findings)