HISTORY COLLECTION
1.BASELINE DATA:
Name : Hospital :
Age : IP.NO :
Sex : Ward :
Religion : : Bed No :
Nationality : Unit :
Occupation : Doctor Name :
Income : Diagnosis :
Address : D.O.A :
2.CHIEF COMPLAINTS:
1.
2.
3.
4.
5.
3.HISTORY OF PRESENT ILLNESS:
CARDINAL SYMPTOMS:--
1)CHEST PAIN:--
A.Onset
Sudden: __________________ Gradual:_______________Location:_____________________
B. Characteristics
Dull:______________ Heavy:________________ Burning:____________________
Crushing:_____________ Squeezing:____________Stabbing:_________________
Tightness:_______________Duration:__________________
C. Precipitating factors:
Emotional Excitement:____________________Temperature:____________________
Deep Sleep:___________________Exertion:__________________
Position Changes:______________________Deep Breathing:___________________
Straining During Bowel movement:___________________________.
D. Relieving factors:--
Rest:____________________________ Sub lingual Nitroglycerin_______________________
02 Administration:___________________ Change In Position:____________________
2)Dyspnea:
Onset:
Sudden:________ __________Gradual:__________________________
Days:_______________________Duration_______________: Hours:____________________
Weeks:_________________Months:__________________ at activity:____________________
Dyspnea at rest:____________________ Cause of Dyspnea:________________________
Dyspnea relieved by:___________________
Orthopnea:
Present:________________Absent:_____________________Relaxed:_________________
Present During day: _____________________or Night:______________________________
Paroxysmal Nocturnal Dyspnea: Present:___________ Absent_______________
3) Weight Loss: Present: ________________Absent:____________
Weight Gain: Present________________Absent:______________
4)Fatigue Present:______________ Absent:_____________
5)Syncope: Present:_____________Absent:_____________
6)Hempotysis: Present:___________ Absent:__________________
7)Palpitations: Present:___________Absent:______________
8)Pedal Edema: Present:______________ Absent:________________
9)Nocturia: Present____________Absent:_____________________
10)Clubbing of Fingers:
Present_____________ Absent__________________
Sudden:___________________ Gradual:_____________
Duration:___________Early Clubbing:________________
Normal:_____________ Late Clubbing:___________
11) Pain or Cramps in Leg: Present:____________ Absent:____________
12) Cyanosis:- Present:___________ Absent:__________
Present during activities: _________At rest:__________________
Oral Mucosa:_______________ Area:____________ Lips:___________
Nail Beds:__________________Earlobe:_________________ Tips of Nose:_____________
Associated Symptoms if any specify:
1
2
3
5)PAST MEDICAL HISTORY:
a)Previous Health status.
Active: ________________Dull:_____________
Frequently Suffered With Health Problem:_______________
b)Previous Hospital Admission
Yes:__________ No________________
If Yes Which Problem:_________________
Specify:_____________________Cause:______________________Hospital_______
admitted:______________or Home treatment:________________________
Regular:________________Irregular:_________________
c)Previous Heart Problem:
Yes:__________________ No:____________
If Yes Specify:__________________
Admitted in the Hospital:___________________
Treatment taken at Hospital:_______________________ or Home:____________
Outcome:______________
d) History of Surgeries:
Yes: _____________ No:_______________
If Yes, Specify the type of surgery:______________
Cause of surgery:_________________ Outcome:___________________
e) History of Childhood diseases:
Yes:___________________ No:_______________
If Yes specify:________________ Duration:_________________
Treatment Taken:______________Outcome:
f) History of Adulthood diseases:
Yes:_______________ No:_________________
If Yes specify:_______________ Duration: _____________
Treatment Taken:___________________________ Outcome:______________
Follow Up: Yes:_________________ No:_________________________
g)History of Immunizations: Yes:______________No:_______________
h) History of Sexually Transmitted Diseases:
Yes:______________No:_____________________
If Yes specify:__________________________Duration:________________
Treatment Taken:___________________Outcome:___________________
i)History of Traumatic Injuries: Yes:_________No:________________
j) History of allergies: Present:____________________Absent:_________________
If any specify name:____________________
Treatment taken: Yes:_________________No:________________________
k) Psychological History: If any specify________________Cause:____________________
FAMILY HISTORY:
Marital Status: Married:_______________Unmarried
Consanguineous Marriage:_______________
Type of Family: Nuclear:________________ Joint:
Position in the Family:_____________
No. Of Adults:_________________________No.Of Children:__________________
Family History & Familial Illness:______________________
Any death occurred recently:_____________________Cause of death:__________________
Any Family History of Cardiac Problem:_____________________
If yes, specify:__________________
FAMILY MEMBERS DETAILS
S.NO NAME AGE SEX EDUCATION OCCUPATION HEALTH
STATUS
FAMILY TREE KEY
Male
Female
Died
Any disease condition
Patient
SOCIO ECONOMIC HISTORY:
Housing :Kutcha:_________________Pucca:___________
Lighting Proper:__________________Improper:_______________
Ventilation :No:______________ Good:________________sufficient:__________________
Drainage: Open:____________________Closed:______________
Educated:__________________Uneducated:_____________
If educated specify:____________
Type of Income:
Daily wage:____________________Weekly wage:__________________
Monthly wage:____________________Yearly:_________________
Type of work:
Sedentary work:____________Moderate work:_______________
Heavy work:_______________ Retired:
Annual Income:
Rs-10,000/-_____________ Rs-Above 10,000/-_______________
Above Rs-50,000/:______________ Above Rs-1lakh:______________
Above Rs-10 lakhs:_____________
PERSONAL HISTORY:
Brushing: No. Of Times:______________ Type of Brush:____________
Dentures : Present:______________ Absent:__________________
Bath: Daily: _______________ No.of Times/day:__________
Bowel movements: Regular:___________ Irregular:________________
Diarrhoea:____________________ Constipation:_____________
Bladder Function: Micturation free:_______Strainful:_______________
Stress Incontinence:________________Dribbling:__________________
Retention:______________
Sleep: Usual bed time:__________________ If any specify:
No.of hours sleep/day:___________
Activities:
Independent:_______________Dependent:___________________
Assistance:_____________________
DIETARY HISTORY
Vegetarian: ____________ Non-Vegetarian:_______________
Egg Vegetarian_______________
No of time Intake/day______________
Name of the Mostly Sometimes Occasionally Never
food
Fruits
Milk and milk
products
Leafy vegetables
Pickles
Sweets
Meat and its
products
Fried food items:
Mostly:__________________ Sometimes_____________________
Occasionally______________________ Never_________________
Habits:
Coffee: No. of times/ day:_____________ Sometimes:________________
Occasionally______________________ Never_________________
Tea: No. of times/ day:_____________ Sometimes:________________
Occasionally______________________ Never_________________
Pan chewing: No. of times/ day:_____________ Sometimes:________________
Occasionally______________________ Never_________________
Alcohol consumption: Amount/day:______________
Daily:__________________ Sometimes:________________
Occasionally______________________ Never_________________
Type of Alcohol:
Tobacco Chewing: No. of times/day:
No. of Packets/day:-------------------------- Daily:________________
Sometimes: _____________ Occasionally:______________
Never:____________________
MENSTRUAL HISTORY:
Age at menarche:___________.regular______________irregular___________
Duration of menstrual cycle____________
Amount of bleeding: average______________severe____________mild_____________
Dysmenorrhea: yes___________no____________
Age of menopause__________________
TREATMENT
NAME OF THE ROUTE DOSE FREQUENCY ACTION
DRUG
INVESTIGATIONS
NAME OF THE PATIENT VALUE NORMAL VALUE INFERENCE
INVESTIGATION
OTHER INVESTIGATIONS
PHYSICAL EXAMINATION
1.General Appearance: Active: ___________ Dull:_________________
Healthy:_____________ Sometimes:_________________
Occasionally:_________________ Never:_________________
Acutely ill:_________________Chronically ill:_____________________
2. State of Comfort:
Comfortable:_________________ Distressed:____________________
Alert: ______________________Apathy:_______________________
Lethargy:___________________ restlessness:____________________
3. Personal hygiene:
Dressed up: __________________ Clean:___________________
Appropriate:______________ Inappropriate:_____________________
4.Body odour:
Present: _____________ Absent: _______________Aromatic:_______________
5. Perspiration:
Profuse:_________________ Less:______________ Absent:___________
6. Posture:
Symmetric: _____________ Asymmetric:_______________
Kyphosis: ______________ Lordosis: ____________ Scoliosis: ________________
7. Body Built:
Obese: ____________ Moderate:____________ Thin:_________________
Height: _______________ Weight:_________________
8. Mood:
Pleasant:___________________Depressed _________________________
Co-operative:_______________Non co-operative:_____________________
9. Level of Consciousness:
Conscious:______________ Semiconscious:_____________________
Unconscious:____________ Stupor:____________________________
Coma:_________________ Drowsy:___________________________
10. Mental Status:
Fearful: ____________________ Anxiety: ____________________
Tense: ____________________ Relaxed: _____________________
Anger: ____________________ Agitated: ____________________
Irritated withdrawn: ____________ Fixed expression:____________
Appropriate eye contact:___________________
11. Speech:
Clear: _________________ Slurred: ______________ Fluent: ________
Murmuring/Stammering: _____________ Appropriate: _______________
Inappropriate:_______________ Aphasia:___________________________________
12. Orientation:
Place:___________________ Time:_________________ Person:_________
VITAL SIGNS:
Temperature :
Pulse :
Rate :_____________ Rhythm:____________ Volume:__________ Tension:________
Respiration:______________Rate:____________ Rhythm:_____________
Blood Pressure:______________
INSPECTION
1. Scalp & Hair:
Thick:_____________ Scanty:_______________ Alopecia:____________
Pediculi:___________ Dandruff:_____________
Texture: Soft:___________ Brown:___________ Gray: ___________
2. Face:
Normal:_____________ Pallor:_________________
Cyanosed:______________ Flushed:________________
Puffiness:______________ Moon face:________________
Periorbital swelling: ______________
3. Eyes:
Symmetric: _____________ Asymmetric:________________
Conjunctiva: ____________ Dry:-______________ Moist:___________
Red: ___________ Yellow: _______________ Pale:_____________
Eyeball:
Normal:________________ Nystagmus:____________
Eyelids:
Normal:_____________ Swollen:________________
Lens:
Transparent:_________________ Opaque:______________
Pupils:
Reacting to light, Constriction: _____________ Dilation:_______________
4. Ears:
Symmetric:____________ Asymmetric:___________________
Pain:
Present:______________ Absent:_______________ Duration:______________
Discharge:
Present:____________ Absent:________________
Types of Discharge:
Pus: __________ Blood:_____________ Serous:____________ Duration: _________
Hearing:
Normal: ____________ Partial deafness:______________ Deafness:___________
5. Nose:
Normal: ______________ Septal deviation:________________
Rhinorrhea: __________ Epistaxis:____________________
Ulcers:_______________ Polyps:______________________
If any other specify:__________________________
6. Mouth:
Oral mucosa:______________ Normal:_____________ Pallor:_____________
Redness: ___________ Ulcers:_________________
Leukoplakia: ___________ If any Specify:______________
7. Lips:
Pink:_____________ Red:________________ Swollen:________________
Bleeding:___________ Ulcerated: ___________________
Cracked:___________ Angular stomatitis: __________________
8. Teeth:
Permanent teeth: ____________ Dentures:_______________
Dental caries:
Present:________________ Absent:__________________
9. Pyorrhea:
Present:____________ Absent:_______________
10. Tongue:
Pale:____________ Red: ___________ Cyanosed:______________
Coated:____________ Pigmented: __________ Ulcerated: ______________
Dry: ______________ Moist:_______________
11. Gums:
Pink: ________________ Red:______________ Swollen:________________
Bleeding:________________ Ulcerated:________________ Pus:____________
If any specify:____________
12. Throat:
Ulcers:______________ Dry:___________ Moist:_________ Smooth:________
13. Neck:
Normal: _______________ Stiffness:______________ Lumps:_________________
14. Jugular veins:
Visible:_______________ Enlarged:________________ Nodular:_______________
15. Chest/Thorax:
Symmetric:_____________ Asymmetric:________________
Abnormal Chest shape:
None: __________ Pigeon chest:____________ Barrel chest:_____________
Funnel Chest:________________ Mass:________________
Nodular:_______________ Tenderness:_______________
Chest: Configuration: A.P Diameter + Lateral Diameter.
Breast:
Symmetric: _______________ Asymmetric:_______________
Tender: ______________ Non tender:_________________
Masses: ________________ Discharge: _______________________
Enlarged:____________ Gynecomastia:________________________
Nipples:
Normal:_____________ Inverted:______________ Retracted:______________
Cracked:______________Tender:____________ Non tender:________________
Abdomen: Skin: Rashes:__________________ Discoloration____________________
Scars:__________________ Striae______________ Turgor__________________
Shape:
Flat_______________ Concave_____________________ Round____________________
Umbilicus________________ Shape_______________ Position_________________
Herniated___________________
Extremities
Symmetry___________________ Asymmetry_________________
Deformity________________
Loss of lower limb_________________________:
Edema: Pitting__________________ Non pitting_________________
Varicose veins: Present___________________ Absent_______________
Genitalia: Male
Uretral ………………..…meatus………………..…..
Central…………..dorsal…….…..ventral………....scrotum……..….
Descended…………..…un descended…………….
Female: Vulva……….…swelling….…….discharge yes….……no………...
If yes specify color………….
CARDIOVASCULAR SYSTEM ASSESSMENT:
INSPECTION:
Abnormal pulsations in precordial areas:
Aortic
Pulmonic
Tricuspid
Mitral
Apical
PALPATION:
1. Apex: Location_______________________
Pulse: Rate:__________________ Rhythm________________
Thrills____________________ Vibration_____________________
2. Aortic area:
Pulsation____________________________
Thrills______________________________ Vibration_________________
3. Pulmonic area
Pulsation____________________________
Thrills______________________________ Vibration_________________
4. Tricuspid area
Pulsation____________________________
Thrills______________________________ Vibration_________________
5. Mitral area
Pulsation____________________________
Thrills______________________________ Vibration_________________
PERCUSSION
Sounds:
Dullness________________ Resonance___________________
If dullness Specify:
AUSCULTATION
AREAS S1 S2 S3 S4 Systolic Diastolic
murmur murmur
N L N L N L N L P A P A
Aortic
Pulmonic
Tricuspid
Mitral
Apical
Key: N-Normal, L-Loud, P-Present, A-Absent
CAROTID ARTERY:
Inspection: ______________
Palpation: Pulse: Rate_______________, Rhythm:________________
Auscultate : Bruits________________ Thrills
JUGULAR VEINS:
Jugular venous pressure/CVP ____________
PERIPHERAL VASCULAR SYSTEM
Peripheral veins:
Inspect: Superficial veins: Normal_______________
Phlebitis: Present: _______________Absent:_________________
Redness and swelling: Present________________ Absent_______________
Peripheral pulses
Various pulse
TYPES RATE/MIN RHYTM VOLUME TENSION
Regular/irregular High/ low Bounding/Feeble
Temporal
Carotid
Apical
Radial
Brachial
Femoral
Popliteal
Dorsalis pedis
Posterior tibial
Peripheral perfusion
Inspect:
Skin: Color: Pink____________ Blue___________________
Temperature: Warmth_______________ Cool___________________
Edema: Present:__________________Absent:_______________
Skin changes :___________________ If any specify:_______________________
Capillary refill test:
Less than 2 seconds _________________
More than 2 seconds _________________
