History

Presenting Complaint & HPC

For each symptom SOCRATES (UK) or NILDOCAAFIAT (UQ)
Site Onset (sudden/gradual) Character Radiations Associations (e.g. pain with food intake) Timing (duration) Exacerbating and alleviating factors Severity (1-10)
Nature Intensity Location Duration Onset Contributing factors Aggravating factors Alleviating factors Frequency Impact Attribute Treatment

Family History (FH)

Do any conditions run in the family? Parents, siblings, grandparents etc. (pedigree) Alive health, age, any conditions, similar presenting complaint Dead age at death, cause of death

Social History (SH)

Home life marriage, children, living situation Vocation - job, education, hobbies, spouses job Mobility need for walking aids, stairs in home Diet average day Exercise

Substance History Past Medical History (PMH)

Hospital visits, previous illness, previous operations Specifically: diabetes, asthma, bronchitis, TB, jaundice, high BP (dont say hypertension), heart disease, stroke, epilepsy, peptic ulcers Medications - tablets, injections, prescriptions, herbal remedies, the pill Allergies & adverse drug reaction Vaccination history Alcohol average per day, CAGE (Cut down, Annoyed, Guilty, Eye opener) Smoking - pack years (= # of packs (20 cigarettes) smoked per day * # of years patient has smoked)

Recreational drugs

Systems Review
General - weight loss, night sweats, lumps, fevers, fatigue / malaise / lethargy, appetite, sleeping (sleepiness, early waking, being woken by pain), itch / rash, recent trauma
Cardio-respiratory - chest pain, dyspnoea (exertional, PND, orthopnoea), oedema, palpitations, cough, wheeze sputum production, haemoptysis Gastrointestinal abdominal pain, difficulty / pain on swallowing, indigestion, nausea / vomiting, change in bowels (constipation / vomiting), stools (colour, consistency, blood, slime, difficulty, urgency, tenesmus) Genitourinary incontinence, dysuria, haematuria, nocturia, frequency, polyuria, hesitancy, terminal dribbling Neurological sight, hearing, smell, taste, seizures, faints, dizzy spells, headaches, paraesthesia, limb weakness, poor balance, function Musculoskeletal pain / stiffness / swelling of joints / muscles, changes throughout the day, functional impact

Sexual History
Indications to ask urethral/vaginal discharge, genital ulcer/rash, abdominal pain, pain on intercourse Last date of intercourse, # partners, homosexual/bisexual, prostitutes Type of sexual practice (vaginal, oral, anal, ano-oral) History of sexual abuse

Menstrual History
All women; esp. abdominal pain, ? endocrine disease, genitourinary symptoms Date of last menstrual period, whether or not periods are regular Age at menarche, whether menopause has occurred Symptoms related to menstruation pain etc.