UNIVERSITY OF SANTO TOMAS

Faculty of Medicine and Surgery

Department of Medicine
Medicine 1 SY 2018-2019
HISTORY DATA BASE CHECKLIST

A. General Data

B. Chief Complaint/Presenting Problem

C. History of Present Illness (put emphasis on OLDCAARTS)

1. Characterize symptoms
O - nset
L - ocation
D - uration
C – haracter
A – ggravating
A -- Associated factors
R – elieving factors
T – emporal factors (sudden, gradual, acute, chronic, intermittent, continuous)
S – everity of symptoms (bearable, progressive, grade pain scale 1-10)
Or
P – recipitating/ palliative factors
Q - uality
R - adiation
S – everity of symptoms
T – emporal factors
2. Associated active medical, surgical or psychiatric problems which may have and impact on the chief
complaint/presenting problem
3. Past experience with symptoms
a. Prior treatment? Medications given? (generic name/brand name/preparation) Dose? Frequency? Route? Duration? Compliance?
Response?)
b. Data from past charts?
c. What has patient done about the symptom(s)?
4. Significant positives and negatives

D. Review of Systems
1. General constitutional symptoms: weight change (loss or gain), fever, chills, malaise, change in appetite, change in sleep pattern (e.g.
insomnia, excessive daytime sleepiness, altered sleep wake cycle)
2. Skin/Hair/Nails: itchiness, color change, hyperpigmentation, hypopigmentation, depigmentation, rash or eruptions, vasomotor change,
texture change, photosensitivity, change in the hair(growth, loss, thickness, brittleness), abnormal nail growth, abnormal nail color, mole
change, excessive sweating
3. Eye: blurring of vision, photophobia, doubling of vision, redness, itchiness, pain, lacrimation, periorbital swelling, history of trauma
4. Ear: deafness, tinnitus, discharge, otalgia(ear pain)
5. Nose: epistaxis, discharge, obstruction, abnormal sense of smell, colds, postnasal drip, sinus pain
6. Mouth: bleeding gums, soreness of tongue, fissure, tongue
abnormality, dental pain, disturbance of taste (e.g. metallic taste)
7. Throat: soreness, tonsillar pain, hoarseness or change in voice
8. Neck: stiffness, limitation of motion, mass, sensation of lump in the throat
9. Breast: mass, pain, discharge, change in the color of the areola, tenderness, trauma, skin change, skin dimpling, galactorrhea,
10. Pulmonary: dyspnea, shortness of breath, cough, sputum (character and quantity) production, hemoptysis cyanosis, wheezing, chest pain
related to respiration, back pain, chest wall abnormality
11. Cardiac: chest pain, easy fatigability, paroxysmal nocturnal dyspnea,
orthopnea, palpitations, syncope, leg edema
12. Gastrointestinal: nausea, vomiting, retching, hematemesis, melena, hematochezia, dysphagia, belching, indigestion, food tolerance,
heartburn, flatulence, abdominal pain, abdominal distention, diarrhea, constipation, anal lesion, abdominal mass, hemorrhoids, change in
stool color or contents (clay-colored, tarry, fresh blood, mucus, undigested food), jaundice
13. Genitourinary: urgency, frequency, urgency, hesitancy, dribbling, weak urinary stream, urinary incontinence, dysuria, hematuria,
nocturia, polyuria, oliguria, anuria, flank or suprapubic pain, stone passage, sandy urine, bubbly urine, edema or swelling(periorbital,
facial, bipedal), urethral discharge, vaginal or cervical discharge, genital lesion, testicular mass, perineal pain, perineal mass, vaginal
bleeding, erectile dysfunction, hernia
14. Musculoskeletal: joint stiffness, pain, swelling, muscle pain, cramps, muscle weakness, muscle wasting, abnormal posture
15. Neurologic: headache, seizures, loss of consciousness, abnormality of sensation, motor dysfunction or weakness or paralysis,
abnormality of coordination, speech disturbance, mental change, head trauma, tremors, loss of memory or ability to concentrate
16. Vascular: phlebitis, variceal pain, variceal swelling, claudication, leg discoloration, extremity temperature change(coldness/warmness)
17. Endocrine: heat-cold intolerance, palpitations, breast change, voice change, polydipsia, polyphagia, polyuria, irritability, slowness in
mentation, distribution and changes in facial or body hair, increased hat or glove size,
18. Hematologic: abnormal bleeding, bruising, pallor, adenopathy
 19. Psychiatric: anxiety, depression, hallucination, delusion, paranoia, violent behavior, mood change, difficulty concentrating, agitation,
tension, suicidal thoughts, irritability, sleep disturbance

E. Past History
1. Birth and developmental history
2. Childhood illness/hospitalizations
3. Adult illness/hospitalizations
4. Surgeries
5. Injuries/Accidents
6. Transfusions/Reactions
7. Allergies
a. nondrug related(type of food, dye, seasonal, environmental)
b. drug-related (class of medication and reaction or symptoms)
8. Obstetric/ Gynecologic History
a. Gynecologic History:
b. Obstetric History
c. Family Planning Method

F. Current Health Status/Risk Factors

1. Health screening (prior blood chemistries or ancillary procedures not related to present illness)
2. Nutrition/ dietary habits
3. Sleep pattern
4. Exercise
5. Smoking
6. Alcohol
7. Environmental exposures
8. Medication data
a. Self-prescribed/over the counter (OTC) drugs
b. Doctor-prescribed drugs
c. Herbal medications
d. Allergies to drugs
e. Illegal drug/Substance abuse
9. Immunizations

G. Family History
1. Current health conditions of parents, sibling, children
2. Determine patterns of disease within a family (genogram if needed)
3. Death: cause, date and ages at death

H. Personal and Social History

1. Marital status
2. Where patient was born and raised and by whom (parents, single parent, or guardians)? Living arrangements and conditions/ Family
structure and background/ How are things at home? Interpersonal relationship with family and peer group
3. Support/Secondary gains: Are there people you rely for help?
a. How have family and friends responded to the illness?
4. Employment history/job satisfaction
5. Sexual history/function
6. Significant life events, deaths, divorce, financial hardships