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History Form - Ahmad Alalmai 2
History Form - Ahmad Alalmai 2
In easy way
Bio Data
Alleviating ………………………………………………………………………
Scoring 1 – 2 – 3 – 4 – 5 – 6 – 7 – 8 – 9 - 10
Exacerbating ………………………………………………………………………
Severity
Q …………………………………………………………………………………………………………………………………………………………………………………………
Qs Content Oder
Associated Symptoms
Ask about the symptoms related to the same system of Chief Complaint, or to possible DDx.
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Risk Factors
Ask about o Smoking, o HTN, o DM, o Hyperlipidemia, o Using the OCP, o Family Hx. of premature ACS, o Hx. of IHD
Constitutional Symptoms
Systemic Review
Chest Pain Headache Chest Pain Joint Pain Jaundice Loin Pain
Change in
Tremor regurgitation …
History Taking
1 In easy way
Did you have any Yes o HTN, o DM, o……………………………… Under control or not ?
chronic Disease ? No -
Did you have any Yes What is it? When it started? under control? Yes No
other disease ? No -
Did you have any Hx. Yes Why? Duration? Inv.
of Hospitalization ? No -
Hx. of Vaccination ? Hx. of Trauma ?
Past surgical Hx. (PSH)
Are your parents alive ? Yes No Mention the Age and Cause of death ……………………………………………………………………………………
Any chronic dis.? What is it? Complications
Any inherited dis.?
Social Hx.
Type Daily amount Duration Illegal sexual contact ? Where?
Smoking Socioeconomic status ?
Q) ………………………………………………………………………………………………
Travel Hx.
Where? When? How long ? Hx. of immobilization ? Yes \ No
Summary
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