Patients Name

: ____________________________________________ Age: _______ R/N: _____________

Gender

:M/F

Ethnicity

: ___________________ Occupation

: ____________________

Date of admission

: ___________________ Date of Discharge

: ____________________

Date of clerking

: ___________________ Time: __________

Source of H(x)

: ___________________

CC:

Marital status

: ____________________

________________________________________________________________________
________________________________________________________________________

Cause:

___________________________________________________________________________________________

HOPI:

Site

_______________________________________________________________________________________

Onset

_______________________________________________________________________________________

_____________________________________________________________________

Character

_______________________________________________________________________________________

Radiation

_______________________________________________________________________________________
_______________________________________________________________________________________

Associate
d
symptom
s
Timing
Exacerba
ting /
Relieving
factors
Severity

_______________________________________________________________________________________
_______________________________________________________________________________________

___________________________________________________________________________
___________________________________________________________________________
EF:____________________________________________________________________________________
RF:____________________________________________________________________________________

_______________________________________________________________________________________

General
Fatigue Fever: _________ weight gain/loss: ___________ skin bruise/ rash swelling excessive /
deprived sleep
Others:

___________________________________________________________________________

________________________________________________________________________________
_____________________________________________________________________________________________________
CVS
Chest pain: _____________________________ Shortness of breath ankle edema palpitations
Others:

___________________________________________________________________________

________________________________________________________________________________
_____________________________________________________________________________________________________
Respiratory
Wheezing chest pain shortness of breath breathing difficulty: __________________
Cough: __________________________________ (sputum) ________________________
Others:

___________________________________________________________________________

________________________________________________________________________________
_____________________________________________________________________________________________________
Gastrointestinal tract (GIT)
Appetite: good/poor/normal dysphagia nausea/vomiting: _______________________ hematemesis:
_____________
Indigestion heart burn abdominal pain Constipation/diarrhea: ________________________________
Stool: colour__________________________consistency_____________________mucus: +ve/-ve
Others:

___________________________________________________________________________

________________________________________________________________________________
_____________________________________________________________________________________________________
Urinary Tract
Urgency hesitancy uneven stream incontinence pain upon urination blood in urine: ___________
nocturia
Urine frequency: _______________ colour: ______________ features: ______________ *multiple partners
Others:

__________________________________________________________________________
_______________________________________________________________________________
____________________________________________________________________________________________________
Musculoskeletal
Joint pain muscle pain restriction of movement lack of motor power can climb up and down stairs with
ease
Others:

__________________________________________________________________________
_______________________________________________________________________________
____________________________________________________________________________________________________
O&G
Married/ divorced pre-menopause /menopause pregnant: ___months Parity (GPA):_______________
Menstrual history: regular/ irregular _______________________________________ *pain during intercourse
Others:

__________________________________________________________________________
_______________________________________________________________________________
____________________________________________________________________________________________________

Past m(x):

Past S(x):

Personal h(x)
Allergies (environment, nature, drugs) :

Drugs

Smoking :
Alcohol :

Dose

years
years

Duration

Indication

Side effects/ concerns

months;
months;

Diet
:
Exercise :
Genogram

Social h(x)

Occupational h(x) :

Travel h(x)

:
Physical Examination

General:

HT:
WT:

CNS:

BP:
Pulse:
Resp:

ENT:

Temp:

CVS:

Resp. :

GIT:

GUT:

MSK:

Others:

Summary:

Provisional d(x): __________________________________________ Final D(x): ___________________________________

Diff d(x): _____________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
Investigations-results:

Signature:
Name:
Sign: _____________________
Name: ___________________