Name: Age: From:

Marital status: Occupation: Gender:

Date of admission: Date of history taking:

Chief complaint: Duration:

Pain:

-Site: -Onset: gradual or sudden.

-character: -Duration:

-Type of pain:1/Radiated. Or 2/ migrated. Or 3/Referred.

And how pain occur pain:

-Intermittent or continuous.

-Exacerbating factor: -Relieving factor:

-Time: -Severity:

-Associated with:

If has anyone of them ask about

1.Duration,2.onset,3.severity,4.Intermittent or
continuous,5.E/R Factors.

1.Dysuria:
2.Hematuria:
3.Nocturne:

4.Frequency:

5.Polyuria. Oliguria. Auria

6.Urinary incontinence:

7.Urgency:

8.Hesitancy:

9.poor urinary stream:

10.Terminal dribbling:

11.Pneumouria:

12.Fever:

13.Nausea and vomiting: 14.Weight loss:

15.Mass: -when noted

-Duration: -How you noted
Systemic Review:

GIT: dysphasia .constipation. -Diarrhea.-Melanie.-Anorexia.

-Jaundice .-Heart burn.-indigestion.- other____________.No.

CVS:-chest pain.-SOB.-palpitation.-edema. -other____.No

RS:-cough. -sputum. -hemoptysis. -wheeze. -other___No.

CNS:-Headache. -seizure.-dizziness. -tremors.-numbness.

-weakness. -vision problems. -abnormal movement.
- loss of consciousness. -other_____________________.No.

MS: -bone,joint,muscle pain.-joint swelling.-other_____.No.

Skin: -itching.-rash.-ulcer.-other_____________________.No.

Endocrine: -heat/cold intolerance.-polydipsia.other____.No.

Past medical history:

Past surgical history: Date:

Complication: Blood transfusion:

Past hospitalization: Why: Date:

History admitted to ICU or RCU.

Family history:

Drug history: Name: Dosage:

Frequency: Allergy:

Social history:

Smoker: How many cig: How long:

Alcohol: Unite: Type:

Diet: Travel history:

Other notes and detail about GIUT system and positive

systemic Review: