Site

Onset
Character
Radiation
Associated symptoms
Time course
Exacerbating/Relieving factors
Severity
History Taking 25/4/14
1. Shake hand (*notice which hand to use if Malay)
2. Introduce myself and give my purpose
3. Ask for patients name and age
4. Ask for patients purpose of visit
5. Explore more on the symptoms (e.g. 5W1H)
6. If its related to pain: SOCRATES
7. Ask for patients thought on their problem

Past Medical History
1. Any chronic diseases?
2. Admitted to hospital, any surgery before?
3. If has previous doctor: what did the previous doctor say/prescribe?
why didnt go back?

Drug
1. Any drug taken to help?
2. Any medical problems related to the drug taken to help?
3. Any supplements taken?
4. Any allergy to any medicine?

Family History
1. Parents, wife, siblings and children
2. If old age, does anyone live with you
3. Any problems now or before?

Social History
1. Smoke/drink (still ask, to avoid future issues)
**BE VERY SENSITIVE ABOUT THIS BY STARTING LIKE THIS:
**I know this may be offensive but may I know if you drink?
2. Ask about work (off or still working, how often, as what)
3. Exercise (how often, still doing)
4. Diet (balanced or not)

*****ASK FOR PATIENTS CONCERN, HOW IT IS AFFECTING HIS/HER LIFE BEFORE GOING OFF*****

Say thank you, will pass the information collected to a doctor and shake hand again (remember
which hand to use!)