І-History

1- Personal history:
● Name: ………………………………………………………………………………..
● Age: ……………………. ● Sex: …………….
● Occupation …………………………..... ● Marital state: .…………………………..
● Residence: ……………
● Special habits (Smoking Index, Alcohol, Drug abuse)……………………………........................
● Menstrual History: • Date of Menarche Or menopause.................................
• Menstrual cycle (rhythm, length, duration, amount and color).
• Dysmenorrhea......................................................................................
• Contraception ( current use )...............................................................

2- Complaint:
● C/O: …………..................................................................● Duration……………...

3- History of the present illness:

1-Analysis of complaint
2- Systemic Review.
3- Symptoms of the related system.
4- Investigation & treatment
5- Diabetes Mellitus and Hypertension (D, C/P, Inv, Comp.)

4- Past history:
● Similar condition………………………………………………………………...
● Operative (Date, Site, Outcome):………………………………………………...
…………...………………………………………………………………………
● Other diseases:………………………………………………………………….
● Drug intake:……………………………………………………………………..
● Repeated blood transfusion:…………………………………………………….

5- Family history:
● Consanguinity:……………………………………………………………….…….
● Similar conditions:……………………………………………………..........
● History of acquired chronic illness: e.g: MI, jaundice, TB, rheumatic fever, epilepsy, asthma, stroke:
................................................................................................................................................. ……………

6- Socioecnomic history:
● (High, Low)
 ІІ-Examination:
General examination:
 General condition:..............................................................................................
 Consciousness:.......................................● Body built:………………………...
 Facial features & expressions:..........................................................................
 Decubitus:……………………………………………………………………...
 Abnormal movements:………………………………………………………..
 Vital signs:
Pulse: ………….(regularity and equality): ……………………………….

R.R.:…………………………. Temp:…………… B.P.:…………………..

 Colors:
Pallor:……………….……Jaundice: ................. Cyanosis:…………………
 Head & neck:
Facial edema:………………………………………………………………...
Neck: lymph node:…………………………………………………………..
Carotid artery:......................................................................................
Thyroid:………………………………………………………………
J.V.P…………………………………………………………………..
Trachea: ………………….……………………………………………
Others: ……………….. ……………………………………………………….
 Limbs:
a- Upper limb:
Clubbing: ……………Muscle wasting:………..Scar:……….
Hand: …………………………………..
b- Lower limbs:
Clubbing……………..Edema…………………. Muscle wasting:…………...
peripheral pulsation :……………………………………………………...
 Skin:
Eruption or pigmentation:…………………………………………………….
Elasticity: …………………………. Scars:…………………………………
 Lymph node enlargement:……………………………………………………
 Joint:..................................................................................................................
 Back:……………………………………………………………………………
 Gait:……………………………………………………………………………