Smart Sheets For History Taking

Sana’a University
Faculty of Medicine & Health Sciences

Division of Medicine
Batch 33
Smart Sheets
for
History Taking
SHEET SUBJECT
1 Smart Sheet for History Taking in Internal Medicine
2 Smart Sheet for History Taking in Surgery
3 Smart Sheet for History Taking in Pediatrics
4 Smart Sheet for History Taking in Gynecology
5 Smart Sheet for History Taking in Obstetrics
Done by: Aiman Al-Sharabi

Batch Representative: Mohammed Al-Nuihi
May, 2021
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done with great love
َ‫لَكََأَيَــــــهَاَالجَمَيــــــل‬
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For feedback, you can contact me via the following username:

aiman61296
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*** Smart Sheet for History Taking in Internal Medicine ***
Source of Information: ........................, Date: ........................, Starting-time: ...................., Completing-time: ...................

• PERSONAL HISTORY (SNAROMS ± MHR)
Sex: …………, Name: …………………………………………………, Age: …………, Residence: ……………………, Occupation: …………………,
Marital Status: …………………………….; for ……………… years; with ………………… children; the youngest is ……………… years old,
Special Habits of Medical Importance:
□ Chewing Qat □ Intaking Shammah □ Using Firewood or Charcoal (Fuelwood Consumption) □ Others: ……………………...
□ Smoking Tobacco:
- Type (□ active smoking □ passive smoking)
- Form (□ cigarettes □ shisha □ mada’a □ cigar □ pipe □ chewed □ others: …………………………………………………………..)
- Index = number of cigarettes per day …… X duration in years …… (□ mild < 100 □ moderate 100-400 □ heavy > 400)
- Cessation/Stoppage (when: ……………………………………, why: ………………………………………)
□ Drinking Alcohol: type (□ bear 250mL □ wine 100mL □ whisky 30mL □ others: ……………), amount per week: ………………
± Menstrual History:
- Her menarche was at …………… years old. She is menopausal for: ………………………………………
- Her first day of the last menstrual period (LMP) was on: ……………………………………… (to consider pregnancy)
- Her menses are (□ regular □ irregular), of (□ scanty □ average □ excessive) amount, of ……….. duration, every ………...
- Lactation ……………………………….……, Contraception (methods: ………………………………., duration: ….………………………………)
± Handedness: ……………………………………………………, ± Related Socioeconomic History: …………………….………………………………
• CHIEF COMPLAINT
The patient is complaining of: (in patient’s own words) ………………………………………..………; since or for …………………..………..
• HISTORY OF PRESENT ILLNESS

The condition started ………………………… ago, when the patient ………………………………………………………………………………………..
(i.e. Before …………………………, the patient was quite well. Then s/he started ….………………………………………………………………)
For analysis of any complaint, ask about its (OCD ↑ ↓ LAST):
- Onset:
1. Acute Onset (□ dramatic within seconds □ apoplectic within minutes □ sudden within hours □ rapid within days)
2. Gradual Onset (□ gradual within weeks □ gradual within months □ gradual within years)
3. Insidious Onset (slow progression without obvious symptoms at first) (the patient is not aware of it developing)
- Course: □ progressive □ regressive □ stationary
& Pattern: □ intermittent/episodic/paroxysmal/coming in attacks (frequency: ……………, duration of each: ……………..)
□ remittent (in between attacks, the patient is ill)
□ continuous (any change in severity: ………………………………………………………)
- Duration: ……………………………………………………………
- ↑ by: ……………………………………………………………………………… ↓ by: ………………………………………………………………………….…
(e.g. eating, fasting, respiration, rest, activity & exertion, postural variation, diurnal variation, seasonal variation,
menstrual cycle, treatment either by herbal medicines or drugs both prescribed or over-the-counter)
- Last attack: ……………………………, Associated Symptoms: ……………………………, Treatment efficacy: …………………………..
For analysis of pain, ask about its (SOCRATES):
- Site: ………………………………….………………………… (□ Somatic pain is often well-localized □ Visceral pain is more diffuse)
- Onset: ……………………………….…………………………
- Character: □ colicky □ burning □ tingling □ stitching □ boring □ stabbing □ crushing □ tugging □ compressive
□ dragging □ heaviness □ throbbing □ sharp □ dull-aching/ill-defined □ cramp-like □ others: ………………..
- Radiation: □ localized □ radiates through local extension to ……… □ referred by a shared neuronal pathway to ………
- Associated symptoms: ……………………………….………………………………………………………….………………………………………………….
- Timing (Pattern, Course, & Duration): ……………………………….……………………………………………………………………………………..
- Exacerbating/provoking factors: ……………………………….………………, relieving factors: ……………………………….……………….
- Severity: □ mild (doesn’t interfere with work) □ moderate (interferes with work) □ severe (the patient seeks help)
(also by comparing with other common pains like toothache or by 1-10 scale if the patient is educated)
1. Analysis of Chief Complaint:
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2. Analysis of Other Symptoms of Involved System:

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3. Review of Other Systems:

(there are no symptoms suggestive of other systems affection)
(other systems are irrelevant to the case)
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[1] Common Constitutional/Toxic/Non-specific Symptoms of General Health:
□ Fever □ Sweating □ Rigors □ Energy: ……………… □ Sleeping: ……………… □ Weight: ……………… □ Appetite: ………………
[2] The Cardiovascular System:

- Symptoms of Pulmonary Congestion:
□ Dyspnea: (exertional grade ………………., postural e.g. orthopnea: ………………., or time-related e.g. PND: ……………….)
□ Cough □ Hemoptysis □ Frequent/Recurrent Chest Infection
- Symptoms of Systemic Congestion:
□ LL or Sacral Edema (before ascites: ………….., pitting: …….…….., pain: ….………, side: ….………, level/extent: ….………...)
□ Ascites (after LL edema: ………………....) □ Hepatic Congestion (pain & jaundice) □ GIT Congestion (dyspepsia, etc.)
- Symptoms of Low Cardiac Output:
□ Headache, Dizziness, Lightheadedness & Syncope ± Convulsions ± Cyanosis □ Blurring of Vision □ Angina Pectoris
□ Oliguria □ Easy Fatigability & Claudication □ Pallor & Coldness of Extremities
- Symptoms of Congenital Heart Disease:
□ Cyanosis (central, peripheral or differential) □ Winter Bronchitis & Exertional Cyanosis
- Symptoms of Enlargement Pressure in Chest: □ Dysphonia (hoarseness of voice) □ Dysphagia □ Dyspnea & Cough
- Symptoms of Increased Blood Pressure (Hypertension):
□ Antihypertensive Drug Intake □ Asymptomatic Headache □ Blurring of Vision □ Tinnitus □ Epistaxis
- Symptoms of Systemic Embolization:
□ Weakness □ Chest Pain □ Painless Hematuria □ Left Hypochondrial Pain □ Blindness □ Intestinal Angina
- Other Cardiac Symptoms:
□ Chest Pain on Exertion (angina pectoris) □ Palpitation: (rhythm …………, precipitating factors …………., rate …………)
- Symptoms of Peripheral Arterial System Affection:
❖ Limb Pain:
□ LL Ischemia: 1. asymptomatic,
2. intermittent claudication with claudication distance & time ………………….., rest time: …………….,
3. night or rest pain,
4. tissue loss (e.g. ulceration or gangrene)
□ Acute Limb Ischemia (pallor, pulselessness, perishing cold, paresthesia, pain, paralysis)
□ Compartment Syndrome (severe unrelieved pain, exacerbated by movement)
❖ Abdominal Pain:
□ Mesenteric Ischemia (severe central abdominal pain after eating, significant weight loss, diarrhea)
□ AAA (asymptomatic until rupture, incidentally discovered during imaging) (abdominal/back pain or pulsation)
❖ Digital Ischemia: □ Blue Toes & Forefoot □ Raynaud’s Phenomenon (pallor → cyanosis → redness)
❖ TIA or Stroke: (focal neurological deficit of rapid onset)
- Symptoms of Peripheral Venous System Affection:
□ VV (pain, itching, swelling, ↑ by prolonged standing, eczema, hemosiderin deposition, lipodermatosclerosis, scar)
□ DVT (pain, swollen limb, cyanosed & mottled skin, venous catheter, repetitive trauma, exacerbated by activity)
□ Chronic Venous Insufficiency (distal cyanosis, varicose eczema, lipodermatosclerosis) & Ulceration (painless)
□ Superficial Thrombophlebitis (red painful area on the skin overlying the tender cord-like vein)
[3] The Respiratory System:

□ Cough: (dry or productive) (brassy/metallic, bovine/hollow, barking/hysterical, or paroxysmal) (starting site: ………..)
□ Hemoptysis:
❖ Attack (frequency …………, date …………, color …………., content …………., preceded by …………., followed by ………….)
❖ Blood (amount ………………….., content ………………….., color …………………..)
❖ Circulatory Compensation (hospitalization ………………….., blood transfusion …………………..)
❖ Dysfunction (disturbance of consciousness, bleeding from other orifices)
□ Sputum Expectoration: (Amount ……………., Content ……………., Color ……………, Consistency ……………, Odor ……………)
□ Chest Pain on Inspiration/Cough □ Cyanosis □ Dyspnea (exercise intolerance) □ Wheeze □ Stridor
□ History of Pleural Effusion Aspiration: (amount …………, color …………., clear/turbid, complicated/not, recurrent/not)
□ Symptoms of Systemic Congestion (Cor-pulmonale) □ Symptoms of Enlargement Pressure in Chest
[4] The Gastrointestinal System:
- Upper GIT Symptoms:
□ Appetite (anorexia, polyphagia, parorexia) □ Taste (ageusia, dysgeusia, cacogeusia) □ Xerostomia □ Waterbrash
□ Halitosis (acetone, stale mousy, fishy/ammoniacal, fecal, or foul dietary) □ Oral Pain & Ulcers □ Dental Problems
□ Dyspepsia:
❖ Reflux-like dyspepsia (heartburn)
❖ Ulcer-like dyspepsia (epigastric pain relieved by food or antacids)
❖ Dysmotility-like dyspepsia (nausea, eructation/belching, bloating/distension/fullness, & premature satiety)
□ Hiccough □ Dysphagia (partial/absolute, for food/drinks/both) □ Odynophagia □ Nausea □ Retching
□ Vomiting (spontaneous/induced, preceded by nausea/not, frequency: …………………….., ACCCO: ………………….………)
□ Hematemesis:
❖ Attack (frequency ………., date ………., color …………., content …………., preceded by …………., followed by ………….)
❖ Circulatory Compensation (hospitalization …………………, blood transfusion ……………….., treated by ………………….)
- Lower GIT Symptoms:
□ Wind/Flatulence (belching, excessive or offensive flatus, abdominal distension, borborygmi) □ Abdominal Pain
□ Abdominal Distension (fat, flatus, feces, fluid - free ascites or encysted, fetus, fibroids & solid masses, functional)
□ Ascites with History of Tapping: (amount ……………., color ……………., clear/turbid, complicated/not, recurrent/not)
□ Abd. or Groin Swelling (discovered …………, number …………, site …………, side ………., size ………., sp. charac. …………)
□ Change in Bowel Habit – Constipation/Diarrhea (frequency: ………………, ACCCO ……………….., tenesmus/dysentery)
□ Blood in Stool – Melena (black offensive shiny tarry stools) or Hematochezia (fresh bleeding per rectum)
[5] The Hepatobiliary System:

□ Jaundice □ Pale Stool □ Dark Brown (tea-like) Urine □ Pruritis/Itching □ Right Hypochondrial Pain or Mass
□ Fat Dyspepsia/Intolerance (abdominal fullness, anorexia, nausea & vomiting) □ Ascites (before LL edema)
□ Bleeding Tendency □ Gynecomastia □ Change in Libido □ Palmar Erythema □ Cachexia □ Drug Intake: ………………..
[6] The Hematological System:

□ Left Hypochondrial Pain or Mass □ LN Swelling □ Bone-ache □ Repeated Infections □ Pallor □ Easy Fatigability
□ Bleeding Tendency (petechiae, purpura, ecchymosis, epistaxis, bleeding gums, bleeding from other orifices, etc.)
[7] The Renal System:

- Upper Urinary Tract Symptoms:
□ Loin/Flank Pain □ Ipsilateral Shoulder Pain □ Fever □ Chills □ Skin Hypersensitivity □ Total Hematuria
- Lower Urinary Tract Symptoms (LUTS) or Prostatism:
a. Filling/Storage/Irritative Symptoms:
□ Dysuria (burning sens. in UTI) □ Frequency □ Urgency/Precipitancy (may → urge incontinence) □ Nocturia
b. Voiding/Obstructive Symptoms:
□ Hesitancy (difficulty starting or maintaining micturition) □ Straining to Void □ Interrupted or Poor-stream
□ Terminal Dribbling □ Sense of Incomplete Voiding □ Urine Retention (may → overflow incontinence)
c. Others:
□ Lower-abdominal/Suprapubic Pain □ Lower Back Pain □ Terminal Hematuria □ Incontinence/Enuresis
- Other Urinary Symptoms:
□ Amount/Volume (polyuria or oliguria) □ Color: …………………………………… □ Odor: ……………………………………
□ Content (frothy, pneumaturia, passage of stones, others: ………………..) □ Urethral Discharge: ………………….
□ Edema (periorbital → facial → sacral → genitalia → general: …………………………………………………………………………….)
[8] The Reproductive System:

- Male Reproductive System:
□ LUTS □ Urethral Discharge □ Infertility □ Scrotal Swelling □ Scrotal Pain □ Genitalia Itching
□ Penile Skin Lesions (phimosis, genital ulcers) □ Gynecomastia □ Loss of 2ry Sexual Hair □ Small Testes
□ Symptoms of Sexual Dysfunction (impotence & erectile dysfunction, absence of morning penile erection, reduced
or loss of libido, problems achieving orgasm, premature ejaculation, failure to ejaculate)
- Female Reproductive System:
□ Breast (swelling, pain, atrophy, skin changes, nipple changes) □ Abnormal Vaginal Bleeding □ Vaginal Discharge
□ Amenorrhea □ Infertility □ Lower Abdominal Pain □ Pelvi-abdominal Mass □ Vulvar Mass or Genital Prolapse
□ Menstrual Disturbance □ Hot Flushes □ Urinary Symptoms (frequency, incontinence, dysuria, fistula)
□ Galactorrhea □ Genitalia Itching □ Hirsutism □ Acne □ Male-pattern Baldness □ Deepening of the Voice
□ Increased Muscle Bulk □ Clitoromegaly
[9] The Nervous System:

- Symptoms of  Intracranial Tension:
□ Bursting Unresponsive Headache □ Projectile Vomiting (at the peak of headache, not preceded by nausea)
□ Blurring of Vision ± □ Coma □ Convulsions
- Symptoms of Cranial Nerves Affection:
❖ CN1: □ anosmia □ parosmia
❖ CN2: □ visual acuity problems …………. □ visual field problems …………. □ visual color problems ………….
❖ CN3,4,6: □ ptosis □ squint □ diplopia
❖ CN5: □ sensory (facial pain, tingling, numbness, hypoesthesia, or anesthesia) □ motor (difficult mastication)
❖ CN7: □ motor (inability to close the eyes → soap enters the eyes & ↑ lacrimation, mouth deviation, dripping of
saliva from the angle of mouth, accumulation of food between gums & cheek)
□ sensory (taste problems in the anterior 2/3 of tongue)
❖ CN8: □ cochlear (tinnitus, diminished hearing, or deafness)
□ vestibular (vertigo, etc.)
❖ CN9,10,11: □ palate (nasal tone, nasal regurgitation)
□ pharynx (dysphagia, choking attacks)
□ larynx (dysphonia/hoarseness of voice, dysarthria)
□ spinal branch of CN11 (inability to turn neck laterally, shoulder drop)
❖ CN12: (tongue deviation, dysarthria)
- Symptoms of Motor Affection:
❖ Weakness:
a. Character:
1. Degree (□ paresis/weakness □ complete paralysis)
2. Tone (□ hypertonia □ hypotonia)
3. Others (□ atrophy □ fasciculations □ trophic changes e.g. hair fall & brittle nails)
b. Distribution:
1. Limb (□ upper limb □ lower limb □ both; started with …………., now …………. is affected more)
2. Side (□ unilateral; right or left □ bilateral; started with …………., now …………. is affected more)
3. Group of Muscles Affected (□ distal or proximal □ extensors or flexors □ abductors or adductors)
❖ Involuntary Movements:
a. Character:
1. Type (□ static □ kinetic)
2. Rhythm (□ regular/rhythmic □ irregular/dysrhythmic)
b. Distribution:
1. Limb (□ upper, lower, or both □ right, left, or bilateral □ distal or proximal)
2. Other Sites (□ head □ neck □ others: …………………..…………………………………..)
❖ Incoordination/Ataxia:
a. Cerebellar: □ LL (staggering/drunken gait)
□ UL (inability to reach the mouth with spoon properly)
b. Sensory: □ LL (unsteadiness during eye closure)
□ UL (a female cannot close back zipper of her dress, or a male cannot wear a tie without a mirror)
- Symptoms of Sensory Affection:
❖ Superficial Sensation:
a. Character:
1. Irritative Lesion (□ pain □ paresthesia, tingling or numbness)
2. Destructive Lesion (□ hypoesthesia □ anesthesia)
b. Distribution: (□ upper, lower, or both □ right, left, or bilateral □ distal or proximal)
❖ Deep Sensation:
□ -ve/Intact (the patient feels that he walks on a solid surface)
□ +ve/Lost (the patient feels as if he walks on cotton)
❖ Cortical Sensation (stereognosis):
□ -ve/Intact (the patient can recognize things in his pocket without seeing it)
□ +ve/Lost (the patient cannot recognize things in his pocket unless he sees it)
- Symptoms of Sphincteric Control Troubles:
□ Problems in Micturition (retention, incontinence, nocturnal enuresis, hesitancy or precipitancy)
□ Problems in Defecation
- Symptoms of Sexual Troubles:
□ Impotence (partial/complete) □ Erectile Dysfunction (organic/psychogenic) □ Morning Penile Erection (weak/not)
- Other Nervous Symptoms:
□ Headache □ Dizziness □ Poor Concentration □ Irritability □ Convulsions
□ Transient Loss of Consciousness (may be due to syncopal attack, orthostatic hypotension, antihypertensive drugs,
autonomic neuropathy in DM) □ Speech Troubles □ Cerebral Affection (e.g. loss of memory, poor IQ)
[10] The Endocrine System & Metabolism:

- Symptoms of Thyroid Gland Affection:
❖ Neck Swelling or Pain.
❖ Symptoms Suggesting Hyperthyroidism:
□ fatigue □ poor sleep □ tremor □ heat intolerance □ excessive sweating □ itching □ onycholysis □ hair loss
□ irritability □ anxiety □ emotional lability □ dyspnea □ palpitation □ ankle swelling □ weight loss □ hyperphagia
□ fecal frequency □ diarrhea □ proximal muscle weakness □ oligomenorrhea □ amenorrhea
□ eye symptoms occurring in autoimmune thyroid disease (grittiness, excessive tearing, retro-orbital pain, eyelid
swelling or erythema, blurred vision, diplopia)
❖ Symptoms Suggesting Hypothyroidism:
□ fatigue □ mental slowing □ depression □ cold intolerance □ weight gain □ constipation □ dry skin or hair
□ carpal tunnel syndrome (hand pain or tingling, wasting of thenar muscles, weakness of thumb abduction)
- Symptoms of Parathyroid Gland Affection:
❖ Commonly Asymptomatic.
❖ Symptoms Suggesting Hyperparathyroidism ~ Hypercalcemia:
□ polyuria □ polydipsia □ renal stones □ peptic ulcer □ abdominal pain □ constipation
□ tender areas of bone fracture or deformity □ psychiatric symptoms (delirium, confusion)
❖ Symptoms Suggesting Hypoparathyroidism ~ Hypocalcemia:
□ post-thyroid surgery □ peripheral hyper-reflexia or tetany/muscle cramps □ perioral or peripheral paresthesia
□ autosomal dominant condition (short stature, round face, shortening of the 4th & 5th metacarpal bones)
- Symptoms of Pituitary Gland Affection:
❖ Symptoms Suggesting Pituitary Adenomas:
□ non-functioning tumors (asymptomatic, visual loss, or headache)
□ prolactinoma: - in female (galactorrhea, oligomenorrhea, amenorrhea, or infertility)
- in males (reduced libido, erectile dysfunction, and reduced 2ry sexual hair)
□ growth hormone excess: - headache & excessive sweating
- gigantism before puberty (tall stature)
- acromegaly after puberty (change in facial features, ↑ in shoe/ring/glove size)
- may be associated with (arthropathy, carpal tunnel syndrome, hypertension, DM,
colonic malignancy, or sleep apnea)
❖ Symptoms Suggesting Hypopituitarism:
□ headache □ vomiting □ visual impairment □ altered consciousness □ ↓ TSH □ ↓ ACTH □ ↓ FSH & LH
- Symptoms of Adrenal Gland Affection:
❖ Symptoms Suggesting Excess Exogenous or Endogenous Glucocorticoid Exposure = Cushing’s Syndrome:
□ proximal myopathy □ fragility fractures □ spontaneous bruising □ violaceous skin striae □ skin thinning
□ central obesity □ recurrent infection □ DM □ hypertension □ hypokalemia
❖ Symptoms Suggesting Inadequate Secretion of Glucocorticoid = Addison’s Disease:
□ weakness □ postural lightheadedness □ nausea □ vomiting □ diarrhea □ constipation □ abdominal pain
□ weight loss □ muscle cramps □ skin hyperpigmentation □ buccal pigmentations
❖ Symptoms Suggesting Overproduction of Mineralocorticoid = Conn’s Syndrome:
□ hypertension □ hypokalemia
❖ Symptoms Suggesting Overproduction of Catecholamines = Pheochromocytoma:
□ paroxysmal hypertension □ paroxysmal palpitations □ paroxysmal sweating
- Symptoms of Gonads Affection:
❖ Symptoms Suggesting Androgen Deficiency in Male = Hypogonadism:
□ loss of libido □ erectile dysfunction □ loss of 2ry sexual hair □ small testes □ gynecomastia
❖ Symptoms Suggesting Androgen Excess in Female = Hyperandrogenism:
□ hirsutism □ acne □ oligomenorrhea
□ virilizing tumor (male-pattern baldness, deepening of the voice, ↑ muscle bulk, clitoromegaly, hirsutism)
- Symptoms of Diabetes:
□ Polyuria & Nocturia □ Thirst □ Weight Loss □ Tiredness □ Mood Changes □ Blurred Vision
□ Bacterial & Fungal Skin Infections □ Itching of the Genitalia (pruritis vulvae in females, balanitis in males)
[11] The Visual System:

□ Altered Vision □ Double Vision (diplopia) □ Visual Loss (blindness) □ Asthenopia □ Squint □ Photophobia
□ Periorbital Edema □ Headache □ Painful Eye □ Dry Eye □ Red Eye □ Itchy Eye (burning or foreign body sensation)
□ Eye Discharge □ Watering from the Eyes (excessive lacrimation or epiphora) □ Black Spots in front of Eyes
□ Colored Halos □ Proptosis □ Ptosis □ Retraction of the Upper Eyelid □ Ectropion □ Eyelids Swellings
[12] The ENT:

- Symptoms of Ear Affection:
□ Deafness (hearing loss) □ Tinnitus □ Ear Discharge □ Headache □ Earache □ Itchy Ear □ Vertigo □ Nystagmus
□ Facial Paralysis □ Ear Swellings □ Ear Deformity □ Orbital Symptoms
- Symptoms of Nose Affection:
□ Nasal Obstruction □ Nasal Discharge □ Epistaxis □ Headache □ Nasal & Facial Pain □ Sneezing □ Snoring
□ Smell (anosmia, hyposmia, cacosmia, parosmia) □ Nasal Swellings □ Nasal Deformity □ Orbital Symptoms
- Symptoms of Throat Affection:
□ Sore Mouth □ Sore Throat □ Trismus □ Dysphonia/Hoarseness of Voice (croaky, breathy, or weak) □ Dysphagia
□ Stridor □ Choking □ Regurgitation □ Respiratory Symptoms □ Neck Swelling □ Weight Loss □ Distant Metastasis
[13] The Musculoskeletal System:

□ Bone-ache □ Myalgia □ Arthralgia □ Joint Swelling, Redness, or Hotness □ Stiffness & Restriction of Movement
□ Deformity □ Weakness & Myopathy
[14] The Skin, Hair, & Nails:

□ Skin Rash (scaly, blistering, or itchy) □ Skin Swelling or Pain □ Skin Lesion (e.g. acne, eczema) □ Skin Itching
□ Skin Dryness □ Skin Discoloration □ Hair Changes (loss, hypertrichosis, or hirsutism) □ Nail Changes
[15] The Symptoms of Psychiatric Disorders:

- Symptoms of Substance Misuse & Dependence:
❖ Pressure Applied to Doctors to Prescribe the Misused Substance:
□ manipulation □ deceit □ threats □ factitious description of illness □ malingering
❖ Complications Arising from the Route of Administration:
a. Intravenous Injection:
1. Local (□ abscess □ cellulitis □ thrombosis)
2. Systemic (□ bacterial endocarditis □ viral hepatitis □ HIV disease/AIDS)
b. Nasal Ingestion: □ erosion of nasal septum □ epistaxis
c. Smoking: □ oral cancer □ laryngeal cancer □ lung cancer
d. Inhalation: □ burns □ chemical pneumonitis □ rashes
❖ Symptoms of Acute Intoxication:
□ emotional & behavioral disturbance □ accidents & injuries sustained in fights
□ medical problems (hypoglycemia, ketoacidosis, aspiration of vomit, respiratory depression)
❖ Withdrawal Phenomena:
□ psychological symptoms (restlessness, anxiety, panic attacks)
□ autonomic symptoms (tachycardia, sweating, pupil dilatation, nausea, vomiting)
□ delirium (agitation, Lilliputian hallucination, illusions, delusions, seizures)
❖ Consequences of Harmful Use:
a. Neurological: □ peripheral neuropathy □ cerebellar degeneration □ cerebral hemorrhage □ dementia
b. Hepatic: □ fatty change of liver □ liver cirrhosis □ liver cancer
c. Gastrointestinal: □ esophagitis □ gastritis □ pancreatitis □ esophageal cancer □ Mallory-Weiss Syndrome
□ malabsorption □ esophageal varices
d. Respiratory: □ pulmonary TB □ pneumonia
e. Skin: □ spider naevi □ palmar erythema □ Dupuytren’s contractures □ telangiectasias
f. Cardiovascular: □ cardiomyopathy □ hypertension
g. Musculoskeletal: □ myopathy □ fractures
h. Endocrine & Metabolic: □ pseudo-Cushing’s syndrome □ hypoglycemia □ gout
i. Reproductive: □ hypogonadism □ fetal alcohol syndrome □ infertility
j. Psychiatric:
□ depression □ hallucination □ blackouts
□ Wernicke’s encephalopathy (nystagmus or ophthalmoplegia with ataxia & delirium)
□ Korsakoff’s syndrome (short-term memory deficits leading to confabulation)
- Symptoms of Depressive Disorders:
❖ Psychological:
□ low/depressed mood (i.e. depression) □ reduced self-esteem □ pessimism □ guilt □ suicidal thinking
□ loss of interest □ loss of enjoyment (anhedonia)
❖ Somatic:
□ reduced appetite □ weight change □ disturbed sleep □ fatigue □ loss of libido □ bowel disturbance
□ motor retardation (slowing of activity)
- Symptoms of Maniac Disorders:
❖ Psychological:
□ high/elevated mood (i.e. mania) □ irritability □ undue optimism □ delusion of grandeur
□ over-talkativeness □ infectious joviality □ recklessness in sexual behavior □ recklessness in spending
❖ Somatic:
□ lack of appetite □ lack of sleep □ over-activity
- Symptoms of Anxiety Disorders:
❖ Psychological:
□ apprehension □ irritability □ worry □ poor concentration □ fear of impending disaster □ depersonalization
❖ Somatic:
□ palpitations □ tremor □ sweating □ diarrhea □ frequency urination □ chest pain □ dyspnea
□ initial insomnia □ fatigue □ dizziness □ headache □ avoidance of medical treatment
- Other Psychiatric Symptoms:
□ Delirium □ Delusions □ Hallucinations □ Confusion □ Self-harm □ Disturbed & Aggressive Behavior
□ Medically Unexplained Somatic Symptoms (………………………………………………………………………………………………………...)
4. Chronic Diseases:
The patient is a known case of: □ DM □ Hypertension □ Atherosclerosis □ Heart/Renal/Liver Disease □ Others: ……………
Its management: □ Uncontrolled □ Controlled under treatment of: ……………………………………………………………………………….
5. Investigations & Treatment:

- Previous Investigations & Treatment:
The patient sought medical advice at ………………., where s/he was ………………., and investigations were done in the form
of ………………., but s/he doesn’t know the results. Or the patient had no previous management for his/her condition.
- Current Admission:
The patient is admitted to ………………., through ………………. or as referred from ………………., on ………………. at ………………..,
& investigations have been done in the form of ………………., and the results have revealed ………………., now the patient’s
condition is managed by ……………….
- Future Investigations & Treatment: The patient is waiting for ……………….……………….……………….……………….……………….……
• PAST HISTORY (SMSO)

- Similar Condition (i.e. recurrence): ……………………………………………………, ……………. ago.
- Medical Condition: □ Disease: ….………….… □ Infection: …………….… □ Trauma: ……………. □ Hospitalization: …………….…….
- Surgical Operation: (name: ……......……, time: …….....……, place: …….....……, reason: …….....….…, complication: ……......……)
- Others: □ Regular Drug Intake: …………….…….……… □ Allergy: …………….….. □ Blood Transfusion □ Exposure to Irradiation
• FAMILY HISTORY (SMP)

- Similar Condition among Family Members: …………………………………………………………………………………………………………………..
- Medical Condition:
□ Diseases among 1st degree relatives (parents, siblings & children): …………….……………………………………………………………….
□ Health of household members (indicating environmental risk factors): …………….………………………………………………………..
- Parental Consanguinity: □ 1st degree (parents are cousins) □ 2nd de. (grandparents are cousins) □ 3rd de. (not related)
• SOCIOECONOMIC HISTORY (EI HSCT)

- Educational Level: □ Illiterate □ Literate □ Educated till grade: …..…………. □ Graduated with …..…………. degree.
- Income or Social Class: □ Low □ Average □ High
- House: (type: …..………………………………, suitability: …..………………………………, crowding: …..……………………. persons/rooms)
- Supply: □ Electrical: …………….………………………….……………………….. □ Water: ….………….…………….…………….………………………
- Contact: □ Animal: …………….………………………….……………………… □ Chemical: …………….…………….…………….………………………
- Travel History: (location: …..………………………….., dates: …..………………………, vaccination & prophylaxis: …..……………………)
• SUMMARY (i.e. the collection of positive findings in history)

- Personal History: ……………………………………………………………………………………………………………………………………………………………
- Complaining of: (in medical terms) ……………………………………………………………………………….; since or for …………………………..
- Associated with: ……………………………………………………………………………………………………………………………………………………….......
- A known case of: …..……………………………………………………………………………………………………………………………………………………….
- Past History: □ Negative □ Positive: …………………………………………………………………………………………………………………………….
- Family History: □ Negative □ Positive: …………………………………………………………………………………………………………………………
- Socioeconomic History: □ Negative □ Positive: ……………………………………………………………………………………………………………
- Medical Interventions: …..………………………………………………………………………………………………………………………………………………
- For examination & further investigations.
• PROVISIONAL DIAGNOSIS (i.e. the collection of positive findings in history & physical examination)
- Summary of History: …..………………………………………………………………………………………………………………………………………………….
- Summary of Physical Examination: …..……………………………………………………………………………………………………………………………
- The diagnosis is most probably: …..………………………………………………………………………………………………………………………………..
1. Cause (etiology & pathology): ……………………………………………………………………………………………………………………………………..
2. Condition of Affected System (anatomy): ……………………………………………………………………………………………………………………
3. Complications (physiology): ………………………………………………………………………………………………………………………………………..
- For further investigations.
*** Smart Sheet for History Taking in Surgery ***

• PERSONAL HISTORY (SNAROMS ± MHR)
Sex: …………, Name: …………………………………………………, Age: …………, Residence: ……………………, Occupation: …………………,
Marital Status: …………………………….; for ……………… years; with ………………… children; the youngest is ……………… years old,
± Menstrual History:
- Her menarche was at …………… years old. She is menopausal for: ………………………………………
- Her first day of the last menstrual period (LMP) was on: ……………………………………… (to consider pregnancy)
- Her menses are (□ regular □ irregular), of (□ scanty □ average □ excessive) amount, of ……….. duration, every ………...
- Lactation ……………………………….……, Contraception (methods: ………………………………., duration: ….………………………………)
± Handedness: ……………………………………………………, ± Related Socioeconomic History: …………………….………………………………
• CHIEF COMPLAINT
The patient is: □ complaining of: (in patient’s own words) ………………………; at ………………………..; since or for …………………..
□ post-trauma: (exact time) ……………………………………………………………… before arrival to hospital.

- Onset:
- Duration: ……………………………………………………………
- ↑ by: ……………………………………………………………………………… ↓ by: ………………………………………………………………………….…
- Onset: ……………………………….…………………………
For analysis of swelling, ask about its (OCD ↑ ↓ LAST + DN SSS):
- Discovery: ………………………………, Number: ……………………………..
- Site: …………..…………………, Side: …………………………….., Special characters: □ affecting patient's ability to work
□ reducible
□ gurgling sensation, colic, dyspepsia
□ double micturition
For analysis of ulcer or deformity, ask about its (OCD ↑ ↓ LAST + NSS):
- Number: ………………………………, Site: ………………………………, Side: ………………………………
For analysis of discharge, ask about its (OCD ↑ ↓ LAST + ACCCO):
- Amount: …………………, Content: ……………………….., Color: …………………, Consistency: …………………, Odor: …………………

………………………………………………………………………………………….………………………………………………………………………………………….……
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……………………………………………………………………….………………………………………………………………………………………….………………………
……………………………………………………………………….………………………………………………………………………………………….………………………
2. General Disturbance of Function & Related Symptoms:

………………………………………………………………………………………….………………………………………………………………………………………….……
……………………………………………………………………………….………………………………………………………………………………………….………………
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❖ Toxic Inflammatory Manifestations: (FAHM) □ Fever □ Anorexia □ Headache □ Malaise
❖ Metastatic Manifestations: (LBLB) (i.e. Malignancy → rapid, short duration, painless, infiltration & metastasis)
- to the Lung in the form of: □ chest pain □ dyspnea □ hemoptysis □ cough
- to the Brain in the form of: □ headache □ projectile vomiting □ blurring of vision □ sensory or motor deficits
- to the Liver in the form of: □ jaundice □ right hypochondrial pain or swelling
- to the Bone in the form of: □ bone pain or swelling □ pathological fracture
❖ General Manifestations:
- Irreducibility (□ yes □ no)
Complications - Intestinal Obstruction (□ absolute constipation □ colic □ abdominal distention □ vomiting)
of Hernia - Inflammation (□ redness □ edema □ pain □ FAHM)
- Strangulation (□ irreducible □ intestinal obstruction □ pain □ no expansile cough impulse)
- Metabolic (□ weight loss inspite of good appetite □ heat intolerance □ excessive sweating).
- Cardiovascular (□ palpitation even at rest).
- Chest (□ dyspnea).
Thyroid Toxic - Nervous (□ tremors □ irritability □ insomnia □ proximal weakness □ diplopia).
Manifestations - GIT (□ polyphagia □ diarrhea).
- Urinary (□ polyuria).
- Skeletal (□ generalized bone-ache).
- Gonadal (□ impotence in males □ menstrual disturbance in females).
Interstitial Cell - Leydig Cell Tumor Masculinization (□ precocious puberty □ extreme muscular development)
Testic. Tumors - Sertoli Cell Tumor Feminization (□ gynecomastia □ loss of Libido □ aspermia)
❖ General Etiology:
Causes Results
□ 2ry TB (2 nights → fever & sweating) (2 losses of → weight & appetite)
□ 2ry Syphilis (skin rash, genital ulcer & FAHM)
□ Infectious Mononucleosis (skin rashes & glandular fever) Generalized
□ AIDS Lymphadenopathy
□ Lymphoma (relapsing/cyclic fever, unexplained loss of weight, rash & splenomegaly)
□ Leukemia (bone-ache & bleeding tendency from body orifices)
□ 1ry TB (young, bad hygiene & cold abscess) Localized
□ Septic Focus (in the draining area) □ Malignant Focus (in the draining area) Lymphadenopathy
□ Schistosomiasis □ Hemolytic Anemia Hepatosplenomegaly
□ Malaria □ Typhoid □ Infective Endocarditis Splenomegaly
□ Chest Problems (e.g. basal pneumonia & infarction) Upper Abdominal Pain
□ Cardiac Problems → embolization Ischemia
Varicose Veins (VV) &
□ DVT (due to postphlebitic limb, prolonged recumbence, pelvic operation or mass)
Swollen Limb
□ Hemolytic Anemia □ Bed Sore □ Trauma □ TB □ Syphilis □ Metastasis □ DVT
□ Varicose Veins □ Ischemia (claudication pain) □ Lymphoma (multiple swellings) Ulcer
□ Diabetic Neuritis (numbness or loss of sensation)
□ Cardiac Problems □ Renal Problems □ Hepatic Problems Bilateral Swollen Limbs
□ Increased Intra-abdominal Pressure (abdominal or pelvic mass, ascites, COPD, etc.) Hernia or Varicocele
□ Hypernephroma □ Herniorrhaphy Varicocele
□ UTI Inguinoscrotal Swelling
❖ Common Associated Manifestations:

□ Hernia □ Visceroptosis □ 1ry Varicose Veins □ Varicocele
Congenital Mesenchymal Weakness/Defect
□ Flat Foot □ Hallux Valgus □ Kyphosis □ Piles
□ Mikulicz’s Disease (enlargement of all salivary glands, enlarged
lacrimal gland & dry mouth)
Salivary Gland Enlargement
□ Sjogren’s Disease (enlarged salivary gland, enlarged lacrimal
gland, dry mouth, dry eyes, generalized arthritis)
□ Intermittent Claudication (muscle ischemia → cramp-like pain)
(Claudication Distance & Time: …………………., Rest Time: ……………)
□ Rest Pain (nerve ischemia → burning pain)
Ischemia & Atherosclerosis □ Angina Pectoris (heart ischemia)
□ Fainting Sensation, Syncopal Attack or TIAs (brain ischemia)
□ Pain, Hematuria or Uremia (kidney ischemia)
□ Colic or Intestinal Angina (intestine ischemia)
Various Syndromes ………………………………………………………………………………………………….…….
3. Local Disturbance of Function & Related Symptoms:

………………………………………………………………………………………….………………………………………………………………………………………….……
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……………………………………………………………………….………………………………………………………………………………………….………………………
❖ Pressure or Infiltration Manifestations of a Swelling on:
Vein □ Facial Edema □ Blackouts □ Dilated Veins on Chest Wall □ Distal Edema □ Varicose Veins
Artery □ Distal Ischemia
□ Pain □ Muscle Wasting □ Deformity □ Ulcer & Skin/Trophic Changes □ Hoarseness of Voice
□ Sensory Changes (tingling, numbness, paresthesia, hypoesthesia, anesthesia)
Nerve □ Facial Nerve Injury/Palsy (inability to close the eyes, mouth deviation, accumulation of food
between gums & cheek, or dripping of saliva from angle of mouth)
□ Horner's Syndrome (ptosis, myosis, enophthalmos, anhydrosis)
Lymphatics □ Lymphedema
Joint □ Restriction or Limitation of Joint Movement
Trachea □ Dyspnea
Esophagus □ Dysphagia
Biliary Tract □ Obstructive Jaundice
Chest □ Chest Pain □ Cough □ Dyspnea
Abdomen □ Abdominal Pain □ Back Pain □ Renal Pain
❖ Discharge:
It is an important manifestation in:
□ Breast Diseases □ Ulcers □ Chronic Sinus of a Swelling □ TB Sinus □ Syphilitic Sinus □ Parotid Gland Diseases
□ Lymphorrhea of a Swollen Limb □ Chronic Osteomyelitis □ Others: …………………………………………………………………...…
❖ Local Manifestations:
Swelling & Lymphadenopathy □ Redness
□ Hemorrhage from Minor Trauma
Varicose Veins □ Superficial Thrombophlebitis (red stricks with pain & fever)
□ Edema □ Pigmentation □ Venous Ulcer □ Dermatitis □ Eczema □ Liposclerosis
□ Thrombophlebitis (FAHM & firm tender cord-like)
Varicocele
□ Sagging Scrotal Skin (interferes with patient's activity) □ Infertility
□ Infertility □ Calcification (hard) □ Pyocele (redness, tender, fever)
Hydrocele □ Hematocele (tender, trauma or attempts for aspiration)
□ Chylocele (elephantoid fever that increases by swelling)
□ Pain □ Coldness □ Skin/Trophic Changes (loss of hair, brittle or fissured nail,
dry scaly skin, tinea pedis interdigital infection, ulceration, tapering digits)
□ Color Changes (pallor, cyanosis, redness) □ Gangrene (black discoloration)
Ischemia □ Sensory Changes (gradual paresthesia, tingling, numbness)
□ Motor Disturbance (wasting, weakness, paralysis, flexion deformity)
□ Sexual Disturbance (impotence as in Le Riche syndrome)
□ Thrombophlebitis (FAHM & lymphadenopathy as in Burger’s disease)
□ Motor Part (deformity, paralysis, wasting)
□ Sensory Part (hypoesthesia, loss of superficial or deep sensation)
Nerve Injury
□ Autonomic Part (redness of skin, loss of sweating)
□ Trophic Changes (loss of hair, brittle or fissured nail, scaly dry skin, ulcers)
- Nipple: □ Discharge □ Deviation □ Destruction
Breast Disease □ Discoloration □ Dermatitis □ Depression/Retraction
- Skin Manifestations: □ Dimpling □ Puckering □ Ulcer □ Redness □ Nodule
- Axillary LNs enlargement: □ Yes □ No
□ Recurrent Serial Attacks of Hotness, Cellulitis & Lymphangitis)
Lymphedema
□ Blebs □ Ulcers □ Heaviness & Limitation of Movement (due to the huge limb)
□ Pain □ Swelling □ Trauma □ Stiffness □ Locking □ Deformity
Joint
□ Feeling of Instability □ Restriction or Limitation of Movement
4. Trauma:
❖ Mechanism of Injury:
The patient was exposed to: ………………………………….………………………………….………………………………….…………………………………
□ a penetrating injury in the form of:
o stab wound (object: …………………………, site: …………………………, depth: …………………………)
o gunshot (□ penetrated from the inlet at …………… to the outlet at ……………, □ stocked inside the body at ……………)
□ a blunt injury in the form of:
o direct blow by ……………
o fall from a height of …………… (in meters)
o fall-down or slipping (could be due to a CVA)
o road traffic accident (RTA): (e.g. □ hitting □ throwing away □ falling down □ sheering due to brake deceleration)
o crash between 2 hard objects: (e.g. □ car > someone standing < wall □ fallen rock > someone’s leg < ground)
□ an airstrike or a bomb explosion (either directly or nearby):
o 1ry → blast/wave trauma (may cause rupture of eardrum, contusions, dyspnea, ARDS)
o 2ry → shrapnels/splinters
o 3ry → falling objects or throwing away
o 4ry → inhalation of gases or chemicals
❖ Way of Transportation:
By whom: …………………………………., By what: …………………………………, Duration till arrival to the hospital: …………………………
❖ Symptoms & Signs:

- In the Head: □ loss of consciousness (for ……………, then became awake by ……………, then …………… happened).
- In the Neck: □ pain □ swelling □ hoarseness of voice □ laryngeal edema (may lead to airway obstruction).
- In the Extremities (UL or LL): □ pain □ swelling □ skin wound □ vessels (i.e. bleeding & stopped by ……………)
□ nerves (i.e. motor & sensory loss: ……………) □ muscles (i.e. edema & hematoma: ……………)
□ bone (i.e. deformity, fracture & protrusion: ……………).
- In the Chest: □ pain □ dyspnea □ cough □ hemoptysis (may cause pallor, anemia, hypotension).
- In the Abdomen: □ pain □ distention □ nausea □ vomiting □ constipation □ bleeding per rectum
□ wound with evisceration (may lead to bowel injury & infection).
- In the Back: □ pain (esp. its radiation due to compression of nerve roots: ……………) □ swelling □ skin wound
□ loss of motor & sensory functions of spinal cord □ loss of sphincters control
❖ Interventions:
………………………………….……………………………………………………………………………………………………………………………………………………..
………………………………….……………………………………………………………………………………………………………………………………………………..
5.Review of Other Systems:

……………………………………………………………………….………………………………………………………………………………………….………………………
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❖ Limb Pain:
❖ Abdominal Pain:

□ Hemoptysis:
□ Dyspepsia:
□ Hematemesis:



c. Others:


❖ Weakness:
a. Character:
b. Distribution:
a. Character:
b. Distribution:
a. Character:
❖ Deep Sensation:


[12] The ENT:




j. Psychiatric:
❖ Psychological:
❖ Somatic:
❖ Psychological:
❖ Somatic:
❖ Psychological:
❖ Somatic:
6.Chronic Diseases:

8. General Postoperative Complications:

□ 1ry Hemorrhage (starting during surgery) (due to surgical trauma, coagulopathy, bleeding
tendency, preoperative use of anticoagulants)
□ Reactionary Hemorrhage (due to postoperative ↑ in BP, insecure ligature slips or dislodged clot)
□ Hematoma Formation (→ mild fever)
□ Tissue Damage & Necrosis at the Site of Operation (→ mild fever)
□ Surgical Trauma (e.g. facial nerve injury during total parotidectomy, impotence following prostate
surgery, recurrent laryngeal nerve injury during thyroidectomy, injury whilst under general
Immediate anesthetic and being transported & handled in the theater)
□ Basal Atelectasis or Minor Lung Collapse (due to general anesthesia) (→ slow recovery, poor color,
mild tachypnea & tachycardia, dyspnea, chest pain, cough, persistent fever)
□ ARDS (→ rapid shallow breathing, severe hypoxemia, scattered crepitation)
□ Shock (due to blood loss, acute MI, PE, or septicemia)
□ Oliguria (due to inadequate fluid replacement)
□ Acute Urinary Retention (managed by adequate analgesia, and if this failed by catheterization)
□ Blood Transfusion or Drug Reaction (→ persistent fever)
□ Pain
□ 2ry Hemorrhage (due to infection eroding a vessel wall)
□ Acute Confusion (due to dehydration, sepsis, pain, sleep disturbance, metabolic disturbance,
medication)
□ DVT (→ leg edema, tenderness & increased warmth of the calf muscles, passive dorsiflexion of the
foot, fever)
□ Aspiration Pneumonitis (→ history of vomiting & regurgitation, rapid onset dyspnea & wheezing)
□ Pneumonia & Chest Infection (→ productive cough, fever)
□ PE (due to DVT) (→ sudden dyspnea & CVS collapse, pleuritic chest pain, pleural rub, hemoptysis,
confusion)
□ Acute Kidney Injury (due to severe or prolonged hypotension caused by antibiotics, obstructive
jaundice, aortic surgery) (→ low urine output with adequate hydration)
□ UTI (→ dysuria, frequency, urgency, persistent fever)
Early
□ Biliary Infection (→ persistent fever)
□ Paralytic Ileus / Functional Intestinal Obstruction (due to analgesia or anesthesia) (→ anorexia,
nausea & vomiting)
□ Mechanical Intestinal Obstruction (due to twisted/trapped loop, fibrinous adhesions) (→ distended
abdomen & absolute constipation, i.e. not passing flatus or stools)
□ Wound Dehiscence (→ serosanguinous discharge, fever)
□ Anastomotic Leakage (→ localized abscess & fistula, delayed recovery of bowel function,
generalized peritonitis, progressive sepsis, fever)
□ Fistula Formation (→ fever)
□ Wound/Surgical Site Infection (→ localized pain, redness, pus discharge, fever)
□ Drip Site Infection or Phlebitis (→ fever)
□ Cellulitis, Abscess Formation (→ fever) or Gas Gangrene
□ Pressure Sores
□ Mechanical Intestinal Obstruction (due to persistent fibrinous adhesions)
□ Persistent Sinus Formation (due to deep chronic abscess)
□ Recurrence of Reason for Surgery (e.g. malignancy)
Late □ Disordered Wound Healing
□ Incisional Hernia
□ Keloid Formation
□ Cosmetic Appearance




- Associated with: ……………………………………………………………………………………………………………………………………………………….......
- A known case of: …..……………………………………………………………………………………………………………………………………………………….
*** Smart Sheet for History Taking in Pediatrics ***

• PERSONAL HISTORY (SNAORE ± HS)
Sex: ………………………, Name: ………………………………………………………………………, Age/DOB: …………………………………………………,
Order of Birth: ………………………, Residence: ……………………………………………………………., Educational Level: ………………………,
± Handedness: ………………………, Special Habits of Medical Importance: ………………………………………………………………………….
• CHIEF COMPLAINT
The patient is complaining of: (in patient’s or mother’s own words) ………………………………………; since or for …………………...

- Onset:
- Duration: ……………………………………………………………
- ↑ by: ……………………………………………………………………………… ↓ by: ………………………………………………………………………….…
- Onset: ……………………………….…………………………

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2. Routine Analysis of Common Constitutional Symptoms:

□ Fever: ……………………… □ Sweating: ……………………… □ Loss of Weight: …………………… □ Loss of Appetite: …………………….
□ Feeding: ……………………… □ Urine Output: ……………………….. □ Activity: ……………………….. □ Sleeping: ………………………..
3. Analysis of Other Symptoms of Involved System:
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❖ Limb Pain:
❖ Abdominal Pain:

□ Hemoptysis:
□ Dyspepsia:
□ Hematemesis:



c. Others:


❖ Weakness:
a. Character:
b. Distribution:
a. Character:
b. Distribution:
a. Character:
❖ Deep Sensation:


[12] The ENT:




j. Psychiatric:
❖ Psychological:
❖ Somatic:
❖ Psychological:
❖ Somatic:
❖ Psychological:
❖ Somatic:
The patient is a known case of: □ DM □ Epilepsy □ Heart/Renal/Liver Disease □ Others: ……………………………………………..…

• PERINATAL HISTORY (very important in patients ≤ 2 years)

- Prenatal/Antenatal/Pregnancy/Maternal History:
Age: …………………………, Health: …………………………, Nutritional Status: …………………………, ANC: ……………………………………….,
Diseases/Bleeding: ……………………, Hospitalization: ……………………, Medication: ……………………, Irradiation: ……………………,
Tetanus Vaccination: ……………………………., Blood Group & Anti-D: ……………………………, Special Habits: ………………………….,
- Natal/Delivery History:
Date of Birth (DOB): ……………………………………………………… Term: □ Pre-term □ Full-term □ Post-term
Mode of Termination: ………………………………………………….. Place of Termination: …………………………………………………….
Time of Rupture of Membrane: ……………………………………. Clarity of Amniotic Fluid: ……………………………………………….
Duration of Labor: ………………………………………………………... Complications, Drugs, or Blood Transfusion: …………………
Outcome & Birth Weight: …………………………………………….. Lactation Period: …………………………………………………………..
- Postnatal/Neonatal History:
□ Cries Immediately □ Neonatal ICU: ……………….…… □ Incubator: ………………….… □ Exchange Transfusion: ………………….…
□ Drugs: ……………… □ Umbilical Catheterization: ………………… □ 1st Urination & Meconium (dark green): ……………………….
□ Movement & Activity □ Sleeping □ Jaundice □ Pallor □ Cyanosis □ Fever □ Convulsions □ Rash □ Bleeding
□ Respiration Difficulty □ Suckling □ Swallowing □ Vomiting □ Urine (volume ………..., color …………, method …………)
- Mother’s Abortions & Abnormal Obstetric History: ………………………………………………………………………….….………………..
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• VACCINATION HISTORY (very important when dealing with infectious diseases)
Complications: ……………….……………….………, Last One: ………………., Campaigns: ……………….., Booster Doses: ……………..…….
• DEVELOPMENTAL HISTORY (very important in patients < 6 years)
Motor Milestones Mental & Behavioral Milestones
Age
Gross Fine/Adaptive Personal/Social Language & Others
2 wk Moves head side to side Regards face Alerts to bell
Cooing,
2 mo Lifts shoulder while prone Tracks past midline Smiles responsively
Searches for sound with eyes
Supports head
3 mo
(neck holding, no lag)
Looks at hand,
Lifts up on hands, Plays with hands, Works toward toy, Laughs,
4 mo
Rolls over Grasps offered rattle Recognizes mother, Squeals
Excited at sight of food
Outreaches objects,
Feeds self,
6 mo Sits alone without support Mouth them, Babbles (meaningless words)
Holds bottle
Transfers hand to hand
Waves bye bye,
Crawls,
Pincer grasp, Plays pat-a-cake, Says Mama/Dada unspecifically,
9 mo Pulls to stand then gets
Bangs 2 blocks together Recognizes father, 2-syllable sounds
into setting position
Perceives stranger
Stoops & stands, Puts block in cup, Drinks from a cup, Says Mama/Dada specifically,
12 mo
Walks Casting Imitates others Says 1-2 other words
Scribbles, Uses spoon & fork, Says 3-6 words,
15 mo Walks backward
Stacks 2 blocks Helps in housework Follows commands
Stacks 4 blocks,
Removes garment,
18 mo Runs Kicks a ball, Says at least 6 words
Feeds doll
Turns pages in 2-3 p.
Puts 2 words together,
Washes & dries hands,
Climbs stairs (up/down), Stacks 6 blocks, Points to pictures,
24 mo Brushes teeth,
Throws overhand Copies line Knows body parts,
Puts on clothes
Understands concept of today
Names pictures,
Speech understandable to
Walks steps alternating
Stacks 8 blocks, Uses spoon well stranger 75%,
feet,
3 yr Wiggles thumb, (spilling little), Says 3-word sentences,
Broad jump,
Cuts with scissors Puts on T-shirt Says name & age,
Rides tricycle
Understands concept of
tomorrow & yesterday
Copies a circle,
Balances well on each Brushes teeth without
Copies a cross, Names colors,
4 yr foot, help,
Recognizes 3 colors, Understands adjectives
Hops on one foot Dresses without help
Draws person + 3 parts
Counts,
Skips,
5 yr Copies a square Understands opposites,
Heel-to-toe walks
Speaks clearly
Balances on each foot 6 Copies a triangle, Define words,
6 yr
seconds Draws person + 6 parts Understands right & left
Any Abnormality in the Developmental History:

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• NUTRITIONAL HISTORY (very important in patients ≤ 2 years)
Onset of Feeding ………..………………….………………………………………………………………………………………………………………………..
Method: ………………….……..……, Regularity: …..…………….……..…….., Duration: ………..………………….….,
Breast Feeding
Problems: (□ gases after feeding □ not enough; why ………..………………….…………………………………….)
Method: ………………….…, Regularity: …..…………….……., Frequency & Amount: …..…………….……..……,
Bottle Feeding Cooling: ………………….…, Sterilization: ………………….…, Problems: ………………………………………………..…
Milk: (type: …………, amount & conc.: ……………, volume of water: …………, type of formula: …………)
Mixed & Solid Starting Time: ………………………………., Type: ………………………………., Amount: …….………………………….,
Feeding Problems: …………………………………………………………………………………………………………………………………….
Starting Time: ………………………………., Type: ………………………………., Amount: …….………………………….,
Weaning
Pica & Supplements: ………………………………., Current Diet: …………………………………………………………….

- Others: □ Drug Intake (by the child or breast-feeding mother) □ Allergy □ Blood Transfusion □ Exposure to Irradiation
• FAMILY HISTORY (SMS PS)

- Significant Events: □ Abortion or Stillbirth □ Death □ Allergy □ Rheumatic Disease, DM, or TB □ Congenital Anomalies
- Parents: (age: ………………/………………, married for: ……..……………, consanguinity: □ 1st degree □ 2nd degree □ 3rd degree)
- Siblings: (number: ……………………, sex & age: ………………………………………………………………………………………………………………..)
• SOCIOECONOMIC HISTORY (P HSCT)

- Parents: (educational level: ………………/………………, occupation: ……………./……………..., income: □ low □ average □ high)

- Associated with: ……………………………………………………………………………………………………………………………………………………….......
- A known case of: …..……………………………………………………………………………………………………………………………………………………….
*** Smart Sheet for History Taking in Gynecology ***

• PERSONAL HISTORY (NAROM PBS)
Name: …………………………………..…………………, Age: ……………, Residence: ………..…………………, Occupation: ………………………,
Marital Status: …………………...; for ………… years; P …………+………… with ………… children; the youngest is ………… years old,
Previous Marriages Number & Duration for Each: ………………………………………………………..……….……, Blood Group: …………,
• CHIEF COMPLAINT
The patient is: □ complaining of: (in patient’s own words) ……………………………………………………..; since or for …………………..
□ coming for family planning.
Common Complaints in Patient’s Own Words Corresponding Medical Terms
Mass protruding from the vulva Genital Prolapse
Continuous dribbling of urine Genitourinary Fistula
Failure or cessation of menstruation 1ry or 2ry Amenorrhea
Menorrhagia, polymenorrhia, metrorrhagia,
Vaginal bleeding
contact bleeding, postmenopausal bleeding
Abdominal swelling Pelvi-abdominal mass
Failure of conception 1ry or 2ry Infertility

- Onset:
- Duration: ……………………………………………………………
- ↑ by: ……………………………………………………………………………… ↓ by: ………………………………………………………………………….…
Chief
Complaint 1. Analysis of Chief Complaint 2. Ass. Symp. of Related Systems
- OCD ↑ ↓ LAST: ………………………………………………..…..
- Amount: □ Scanty □ Average □ Excessive
Vaginal - Content: ……………………………….…………………………...… - Gynecological Symptoms:
Discharge - Color: ……………………………….……………………………….…. □ Itching □ Pain □ Swelling
- Consistency: □ Watery □ Viscid
- Odor: □ Odorless □ Offensive
- OCD ↑ ↓ LAST: ………………………………………….………..
- Preceding Event: □ Short Period of Amenorrhea
□ Contraceptive Pills □ IUD Insertion
□ Psychological Trauma □ Others: ………………………..
- Gynecological Symptoms:
Vaginal - Amount (No. of Pads/Diapers per Day):
□ Discharge □ Pain □ Swelling
Bleeding □ Scanty/Spotting □ Mild □ Moderate
□ Excessive/Severe with Blood Clots
□ Contact bleeding after …………………………….…………
- Rhythm: □ Regular/Cyclic □ Irregular/Acyclic
- Color: □ Fresh bright red □ Dark red
- Site: ………………………………….…………………………………..
- Onset: ……………………………….………………….………………
- Character: …………………………………………………..………..
- Radiation: …………………………………………………..………..
- Associated symptoms: ……………..………………..………..
- Timing: - Gynecological Symptoms:
Pain
a. pattern: ……………..………………..…………………….…….. □ Bleeding □ Discharge □ Swelling
b. course: ……………..………………..…………………………….
c. duration: ……………..………………..………………………….
- Exacerbation/provoking & relieving factors:
……………..……………...……………………………………………...
- Severity: □ mild □ moderate □ severe
- Gynecological Symptoms: …………………….
- Congestive Symptoms: □ Dysmenorrhea
□ Leukorrhea □ Menorrhagia
- Urinary Symptoms: □ Fever □ Loin Pain
- OCD ↑ ↓ LAST: …………………………………………………...
Genital □ Frequency □ Stress Incontinence
e.g. straining is an aggravating factor
Prolapse □ Difficulty □ Dysuria □ Inability to
e.g. lying down is a relieving factor
complete micturition unless the mass is
reduced by fingers
- Rectal Symptoms:
□ Sense of incomplete act of defecation
- Gynecological Symptoms: □ Amenorrhea
□ Vulval Soreness □ Pruritus Vulvae
- OCD ↑ ↓ LAST: …………………………………………………...
- Possible Etiology:
Genitourinary - Type:
□ 5 days after prolonged difficult delivery
Fistula □ Partial (has the desire to micturate)
□ Immediately after instrumental delivery
□ Complete (day & night without desire to mict.)
□ Surgical trauma during hysterectomy, etc.
□ Pelvic abscess/malignancy/irradiation
- Development of 2ry Sexual Characters:
□ Axillary Hair □ Pubic Hair □ Breast Dev.
- Symptoms Suggestive of Pregnancy:
□ the 1st day of LMP □ Pregnancy Test
□ Nausea & Vomiting □ Quickening
□ Lightening □ Frequency of micturition
- Symptoms of Cryptomenorrhea:
□ Cyclic Lower Abdominal Pain
- OCD ↑ ↓ LAST: …………………………………………………...
Amenorrhea □ Abdominal Enlargement
□ Attacks of Urine Retention
- Sym. Suggestive of Hypothalamic Lesion:
□ Psychological Disturbance
□ Headache and Blurring of Vision
- Sym. Suggestive of Pituitary Lesion:
□ Sheehan’s Syndrome □ Galactorrhea
- Sym. Suggestive of Hyperandrogenism:
□ Hirsutism □ Acne □ Acanthosis Nigracans
□ Amenorrhea □ Pain □ Bleeding
□ Discharge □ Virilization
- OCD ↑ ↓ LAST: …………………………………………………... - Urinary & GIT Symptoms: ……………………..
- Discovery: …………………………………………………............ - Trauma: □ Accidental □ Surgical
Pelvi-
- Number: ………………………..…………….………………………. - Inflammatory Symptoms:
abdominal
- Site: …………………………………..…………………………………. □ Non-specific (fever & headache)
Mass
- Side: ……………………………….………..………………………….. □ Specific for TB (night fever, etc.)
- Special Characters: ……………………………..……….………. - Malignant Neoplasm Symptoms:
□ Rapid Rate of Growth □ Cachexia
□ Unilateral Lower Limbs Edema
□ Metastatic Symptoms
- Male Factors: □ Semen Analysis: …………….…
- Ovarian Factors:
□ Irregular Cycles
□ Regular Spasmodic Dysmenorrhea
□ Regular Premenstrual Mastalgia
The condition started ………………………… ago, in the □ Ovulatory Pain, Bleeding, or Discharge
Infertility form of failure of conception, in spite of regular - Tubal Factors:
marital life without the use of contraception. □ Previous Abd. Operations: ………………………
□ Previous Bilateral Lower Abd. Pain
□ History of Fever
- Cervical or Vaginal Factors:
□ Vaginal Discharge □ Backache
- Others: □ Galactorrhea □ Hirsutism

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[1] Common Constitutional Symptoms of General Health: (esp. reviewed in vaginal bleeding & pelvi-abdominal mass)
[2] The Cardiovascular System: (esp. reviewed in genital prolapse, amenorrhea, & vaginal bleeding)
❖ Limb Pain:
❖ Abdominal Pain:
[3] The Respiratory System: (esp. reviewed in amenorrhea)

□ Hemoptysis:
[4] The Gastrointestinal System: (esp. reviewed in genital prolapse & pelvi-abdominal mass)
□ Dyspepsia:
□ Hematemesis:
[5] The Hepatobiliary System: (esp. reviewed in genital prolapse & pelvi-abdominal mass)
[6] The Hematological System: (esp. reviewed in vaginal bleeding)

[7] The Renal System: (esp. reviewed in fistula, vaginal bleeding, & pelvi-abdominal mass)
c. Others:


❖ Weakness:
a. Character:
b. Distribution:
a. Character:
b. Distribution:
a. Character:
❖ Deep Sensation:
[10] The Endocrine System & Metabolism: (esp. reviewed in amenorrhea & vaginal bleeding)

[12] The ENT:




j. Psychiatric:
❖ Psychological:
❖ Somatic:
❖ Psychological:
❖ Somatic:
❖ Psychological:
❖ Somatic:

• MENSTRUAL HISTORY
- Her menarche was at: …………… years old. She is menopausal for: ………………………………………
- Her first day of the last menstrual period (LMP) was on: ………………………………………
- Her menses are (□ Regular □ Irregular), of (□ Scanty □ Average □ Excessive) amount, of ……..….. duration, every ……..…
- Associated with premenstrual (□ Headache □ Nausea □ Others: …………………………………………………………………………………).
- Associated with dysmenorrhea (□ 1ry spasmodic pain starts at onset □ 2ry congestive pain ends by onset).
- Associated with intermenstrual (□ Mittleschmerz Pain □ Ovulatory Spotting □ Ovulatory Discharge/Cascade).
• OBSTETRIC HISTORY
- Deliveries:
Antenatal Mode of Place of
No Time Duration Outcome Puerperium Lactation
Period Termination Termination
1
- Abortions:
Clinical Mode of Place of Condition of Post-abortion
No Time Duration
Picture Abortion Termination Abortus Period
1
• CONTRACEPTIVE HISTORY
- Use: □ Yes □ No
- Methods: □ Pills □ Injections □ Implants □ IUD □ Condoms □ Tubal Ligation □ Others: ………………………………………………..
- Starting Time: ………………………………………………………………….., Duration: ……………………………………………………………………….…
- Stopped or Removed: □ Due to complications □ For seeking fertility □ Others: ………………………………………………………….…


• SEXUAL HISTORY (esp. in case of infertility)

She has sexual intercourse ………………………… times per week,
With no sexual troubles or symptoms (□ Dyspareunia □ Vaginismus □ Frigidity □ Others: …………………………………………….)
• HUSBAND HISTORY
Marital Status: …………………...; for ………… years; P …………+………… with ………… children; the youngest is ………… years old,
Other Marriages number & number of children for each Marriages: …………………………………………,
General Medical Diseases: ………………………………………………………….., Drug Intake: …………………………………………………………….
Previous Important Surgery & Operations: …………………………………., Exposure to Radiation: ……………………………………………


- Associated with: ……………………………………………………………………………………………………………………………………………………….......
- A known case of: …..……………………………………………………………………………………………………………………………………………………….
*** Smart Sheet for History Taking in Obstetrics ***

• PERSONAL HISTORY (NAROM GBS)
Marital Status: …………; for ……… years; Gravidity & Parity: □ Primigravida □ Multigravida; ……… Gravida, Para …… + …..,
Blood Group: ……………….…, Special Habits of Medical Importance:
• CHIEF COMPLAINT
She is pregnant in the ………… month: □ complaining of: (in patient’s own words) ……………..………..…; since or for .…………
□ coming for routine antenatal care (ANC).
Common Complaints in Patient’s Own Words Corresponding Medical Terms
Recurrent miscarriage/loss of early pregnancy Habitual abortion
Repeated intrauterine fetal death IUFD (Rh-incompatibility with pregnancy, etc.)
Dyspnea, easy fatigability, LL swelling, etc. Heart disease with pregnancy
Polyuria, dry mouth, polydipsia, weight loss, etc. DM (chronic or gestational)
Headache, lower limb swelling, etc. Hypertension (chronic, gestational, or preeclampsia)
Vaginal bleeding with pregnancy Antepartum hemorrhage
Lower abdominal pain Labor pain

She is pregnant (Gestational Age) ………..... weeks and …..…….…. days, as her 1st day of the Last Menstrual Period (LMP)
was on ……….……….………..…., so the Expected Date of Delivery (EDD) will be on …………………….………
- Onset:
- Duration: ……………………………………………………………
- ↑ by: ……………………………………………………………………………… ↓ by: ………………………………………………………………………….…
Chief
Complaint 1. Analysis of Chief Complaint 2. Ass. Symp. of Related Systems
- OCD ↑ ↓ LAST: ………………………………………………..…..
- Amount: □ Scanty □ Average □ Excessive
Vaginal - Content: ……………………………….…………………………...… - Gynecological Symptoms:
Discharge - Color: ……………………………….……………………………….…. □ Itching □ Pain □ Swelling
- Consistency: □ Watery □ Viscid
- Odor: □ Odorless □ Offensive
- OCD ↑ ↓ LAST: ………………………………………….………..
- Preceding Event: □ Short Period of Amenorrhea
□ Contraceptive Pills □ IUD Insertion
□ Psychological Trauma □ Others: ………………………..
Vaginal - Amount (No. of Pads/Diapers per Day):
□ Discharge □ Pain □ Swelling
Bleeding □ Scanty/Spotting □ Mild □ Moderate
□ Excessive/Severe with Blood Clots
□ Contact bleeding after …………………………….…………
- Rhythm: □ Regular/Cyclic □ Irregular/Acyclic
- Color: □ Fresh bright red □ Dark red
- Site: ………………………………….…………………………………..
- Onset: ……………………………….………………….………………
- Character: …………………………………………………..………..
- Radiation: …………………………………………………..………..
- Associated symptoms: ……………..………………..………..
- Timing: - Gynecological Symptoms:
Pain
a. pattern: ……………..………………..…………………….…….. □ Bleeding □ Discharge □ Swelling
b. course: ……………..………………..…………………………….
c. duration: ……………..………………..………………………….
- Exacerbation/provoking & relieving factors:
……………..……………...……………………………………………...
- Severity: □ mild □ moderate □ severe
3. Retrograde Analysis of Pregnancy:

- Consultation before pregnancy: □ Planned □ Unplanned
- Pregnancy is discovered by: □ Miss-period (amenorrhea) □ Nausea & Vomiting □ Others: ……………..………….………….……
- Pregnancy is confirmed by: □ Pregnancy Test: …………………….……… □ Ultra-sound □ Others: ………………..………….….………
- 1st Trimester:
□ Nausea & Vomiting □ Abdominal Pain □ Vaginal Bleeding □ Cough □ Dysuria □ UTI □ Frequency of Micturition
□ Hospitalization □ Others: …………………………………………………………………………….………………………………….....…………….……….
- 2nd Trimester:
□ First Quickening/Fetal Movement was on ……………………..………, since that time it is about …….…………… times per day
□ Nausea & Vomiting □ Abdominal Pain □ Vaginal Bleeding □ Cough □ Dysuria □ UTI □ Frequency of Micturition
□ Hospitalization □ Others: …………………………………………………………………………..…….…………………………………………………….….
- 3rd Trimester:
□ Lightening □ Frequency of Micturition □ Others: …………………………..…………………………………………………….……………………
- Warning Symptoms of Pregnancy:
□ Persistent Headache □ Excessive Blurring of Vision □ Excessive Vomiting □ Coma □ Convulsions
□ Epigastric Pain □ Abdominal Pain □ Diminished Fetal Movement □ Vaginal Bleeding or Discharge □ LL Edema
4. Antenatal Care (ANC):

Getting ANC: …………………….… (□ Regular □ Irregular), Outcomes: …………..………………………….……………..…………………..…..….

……………………………………………………………………….………………………………………………………………………………………….………………………
……………………………………………………………………….………………………………………………………………………………………….………………………
……………………………………………………………………….………………………………………………………………………………………….………………………
……………………………………………………………………….………………………………………………………………………………………….………………………
……………………………………………………………………….………………………………………………………………………………………….………………………
……………………………………………………………………….………………………………………………………………………………………….………………………
……………………………………………………………………….………………………………………………………………………………………….………………………
……………………………………………………………………….………………………………………………………………………………………….………………………

❖ Limb Pain:
❖ Abdominal Pain:

□ Hemoptysis:
□ Dyspepsia:
□ Hematemesis:



c. Others:


❖ Weakness:
a. Character:
b. Distribution:
a. Character:
b. Distribution:
a. Character:
❖ Deep Sensation:


[12] The ENT:




j. Psychiatric:
❖ Psychological:
❖ Somatic:
❖ Psychological:
❖ Somatic:
❖ Psychological:
❖ Somatic:

• MENSTRUAL HISTORY
- Her menarche was at: …………… years old. She is menopausal for: ………………………………………
- Her first day of the last menstrual period (LMP) was on: ………………………………………
- Her menses are (□ Regular □ Irregular), of (□ Scanty □ Average □ Excessive) amount, of ……..….. duration, every ……..…
- Associated with premenstrual (□ Headache □ Nausea □ Others: …………………………………………………………………………………).
- Associated with dysmenorrhea (□ 1ry spasmodic pain starts at onset □ 2ry congestive pain ends by onset).
- Associated with intermenstrual (□ Mittleschmerz Pain □ Ovulatory Spotting □ Ovulatory Discharge/Cascade).
• OBSTETRIC HISTORY
1. Gravidity & Parity:
Gravida …..…………..., Para …………..……. + …………..……., with ……….………. children, ….….…….... males, …..……..…. females,
the oldest is ………………. years old, the youngest is ………………. years old.
2. Past Obstetric History (Deliveries):

Antenatal Mode of Place of
No Time Duration Outcome Puerperium Lactation
Period Termination Termination
1
2
3
4
5
6
7
8
3. Past Obstetric History (Abortions):

Clinical Mode of Place of Condition of Post-abortion
No Time Duration
Picture Abortion Termination Abortus Period
1
2
3
4. Contraceptive History:
- Use: □ Yes □ No
- Methods: □ Pills □ Injections □ Implants □ IUD □ Condoms □ Tubal Ligation □ Others: ………………………………………………..
- Starting Time: ………………………………………………………………….., Duration: ……………………………………………………….…………………
- Stopped or Removed: □ Due to complications □ For seeking fertility □ Others: …………………………………………….………………
- Medical Condition: □ Disease: ….………….. □ Infection: …………….… □ Trauma: ……………. □ Hospitalization: …………….…….
- Surgical Operation: (name: ……......……, time: …….....…., place: …….....……, reason: …….....….…, complication: ……......……)
- Others: □ Regular Drug Intake: …………….…….……. □ Allergy: …………….….. □ Blood Transfusion □ Exposure to Irradiation

- Similar Condition among Family Members: □ Twins □ Preeclampsia □ Congenital Fetal Anomalies □ Others: .……………
• SOCIOECONOMIC HISTORY (EI HSCTH)

- Husband History: (name: ……….…….……….………., age: …….…., occupation: ……….……….……, education level: …………….……,
special habits of medical importance: □ smoking (……….……….…) □ chewing Qat □ others: ……………..)

- Personal History: ………………………………………………………………………………………………………………, Pregnant: …………..…. weeks
- Associated with: ……………………………………………………………………………………………………………………………………………………….......
- A known case of: …..……………………………………………………………………………………………………………………………………………………….

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Sana’a University

Faculty of Medicine & Health Sciences

1 Smart Sheet for History Taking in Internal Medicine

2 Smart Sheet for History Taking in Surgery

3 Smart Sheet for History Taking in Pediatrics

4 Smart Sheet for History Taking in Gynecology

5 Smart Sheet for History Taking in Obstetrics

Done by: Aiman Al-Sharabi

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Source of Information: ........................, Date: ........................, Starting-time: ...................., Completing-time: ...................

• HISTORY OF PRESENT ILLNESS

2. Analysis of Other Symptoms of Involved System:

3. Review of Other Systems:

[2] The Cardiovascular System:

[3] The Respiratory System:

[5] The Hepatobiliary System:

[6] The Hematological System:

[7] The Renal System:

[8] The Reproductive System:

[9] The Nervous System:

[10] The Endocrine System & Metabolism:

[11] The Visual System:

[12] The ENT:

[13] The Musculoskeletal System:

[14] The Skin, Hair, & Nails:

[15] The Symptoms of Psychiatric Disorders:

5. Investigations & Treatment:

• PAST HISTORY (SMSO)

• FAMILY HISTORY (SMP)

• SOCIOECONOMIC HISTORY (EI HSCT)

• SUMMARY (i.e. the collection of positive findings in history)

Source of Information: ........................, Date: ........................, Starting-time: ...................., Completing-time: ...................

• HISTORY OF PRESENT ILLNESS

1. Analysis of Chief Complaint:

2. General Disturbance of Function & Related Symptoms:

❖ Toxic Inflammatory Manifestations: (FAHM) □ Fever □ Anorexia □ Headache □ Malaise

❖ Common Associated Manifestations:

3. Local Disturbance of Function & Related Symptoms:

❖ Symptoms & Signs:

5.Review of Other Systems:

[2] The Cardiovascular System:

[3] The Respiratory System:

[5] The Hepatobiliary System:

[6] The Hematological System:

[7] The Renal System:

[8] The Reproductive System:

[9] The Nervous System:

[10] The Endocrine System & Metabolism:

[11] The Visual System:

[12] The ENT:

[13] The Musculoskeletal System:

[14] The Skin, Hair, & Nails:

[15] The Symptoms of Psychiatric Disorders:

7. Investigations & Treatment:

8. General Postoperative Complications:

• PAST HISTORY (SMSO)

• FAMILY HISTORY (SMP)

• SOCIOECONOMIC HISTORY (EI HSCT)