History taking format

1 . IDENTIFICATION DATA

Name Age

Sex Bed No

Ward Regd. No

Under Doctor Diagnosis

Date Of Admission Date Of Surgery

Name Of The Surgery Date Of Discharge

2. CHIEF COMPLAIN ON ADMISSION: (With Onset And Duration Of Illness)

3. PRESENT COMPLAIN:

4. MEDICAL HISTORY:

PAST-

PRESENT-

5. SURGICAL HISTORY:

PAST-

PRESENT-

6. HEREDITARY HISTORY:
7. PERSONAL HISTORY:

Blood Group History Of Previous Blood Transfusion:

Allergic History: Addiction:

Personal Hygiene: Spiritual Habit

8. SOCIO-ECONOMIC CONDITION:

Type Of House: Ventilation

Drainage System : Electricity:

Drinking Water Supply: Sanitary System:

9. FAMILY HISTORY:

S/ Name Age Sex Relation Occupatio Incom Marital Any Disease Remarks And
Ln n e Status Treatment
o

10. INVESTIGATIONS:

S/ Name Of The Date Patient’s Value Normal Value Remarks

L Investigation
No

11. TREATMENT:

12. CONCLUSION: