GUIDE TO

HISTORY TAKING
by NRC,RN

HISTORY TAKING
A. BIOGRAPHICAL DATA:
Date :

weight 4 height filipino

4. C.
Name: __________________________________________________________________
Age: _____
26,19 As Msg
-
Sex: _____
- M ihuhhded
Civil Status: ___________ Race: __________
Birthdate: __________
19 Any -
never -
Place of Birth: ___________
Angeles coty Religion: ____________
Catholic
.

Address: _______________________________________
Angeles City Doctor
Occupation: ___________
Educational Attainment:
Elementary High School College Never Been To
Graduate Graduate Graduate School
Provider of History: Patient: _____ Others: ______________
Source of the Referral (if any): ________________

B. CHIEF COMPLAINTS/ REASONS FOR SEEKING HEALTH CARE: (Max. of 2 complaints)

Numbers dielhhhlcl
________________________________________________________________________
.

C. HISTORY OF PRESENT HEALTH CONCERN:

abdominal pain . discomfort abd
, .
cramp
.

|| USING OLD CART ||

IIdey priorIs it better? ________ Worse? ________

Onset: When did it begin? ________
The same ________ since it began?
upper cruanddont
Location: Where? __________________________
left
Duration: How long does it last? _______________ Does it recur? Yes ___ No ___
Character/ General Observation/ Appearance: (How does it feel, look, smell, sound, etc.?
If w/ Pain or Discomfort, rate the intensity using the Pain Scale: 1 [lowest] 10 [highest])
21£ $6110
________________________________________________________________________
________________________________________________________________________
Aggravating/ Associated/ Relieving Factors:
What makes it worse? ______________________________________________________
What makes it better? ______________________________________________________
What other symptoms do you have with it? _____________________________________
Will you be able to continue doing your work or other activities like leisure or exercise? ___
Radiation: Does it radiate? Yes ___ No ___ ✓ If yes, where? __________________
Timing: What provokes or triggers the problem? _________________________________
What time does it occasionally occur? ________________ Intermittent Perin

|| USING OPQRST ||
number
Gheusspstnrto .

Onset: When did it begin? ________

Ifor Is it better? ________ Worse? ________
The same ________ since it began?
Palliative/ Provocation:
What makes it better? _______________________________________________________
What provokes or makes the problem worse? ____________________________________
affect the sleep

Granet S .
-
medication .
 GUIDE TO
HISTORY TAKING
by NRC,RN

What other symptoms do you have with it? ______________________________________

Will you be able to continue doing your work or other activities like leisure or exercise? ____
Quality: How does it feel, look, smell, sound, etc.? ________________________________
_________________________________________________________________
Region & Radiation: Where? _________________ Does it radiate? Yes ___ No ___
If yes, to where? __________________
Severity: If w/ Pain or Discomfort, rate the intensity using the Pain Scale: 1 [lowest] 10
[highest] _________________________________________________________
Time: How long does it last? _______________ Does it recur? Yes ___ No ___

TAKE NOTE: With the information that you have gathered using the OLD CART and OPQRST
technique, you should be able to construct the narrative report of the History of Present Illness
appropriately and in chronological order***

Smoking? No ___ How many pack years? ____ *Formula:

Alcohol/ Drugs? 8- Hines -

aeatevgstaoi ,
nonrfonf
Pattern of Use? ___________________________smelt
Family History? ___________________________
2- Cup .

What Type? ______________________________

Rxn(s), injuries, or conflict in job/ personal
relationships/ legal problem? _______________
TAKE NOTE: You may include history of Smoking/ Alcohol intake, Medications taken, Allergies,
IF RELEVANT/ RELATED
TO THE CHIEF COMPLAINT. Also include current meds./ supplements/ contraceptives.

D. PAST MEDICAL HISTORY:

PROBLEMS AT BIRTH: _____________________________________________________

Ps thinner .

CHILDHOOD ILLNESSES: CHILDHOOD IMMUNIZATIONS:

Chickenpox VACCINE NOT GIVEN NOT GIVEN
BCG Vaccine
Mumps
Rubella (German Measles) DPT Vaccine
I
Rubeola (Red Measles) OPV Vaccine
Rheumatic Fever
Others: ____________________
HEPA B Vaccine
MEASLES Vaccine
É
ALLERGIES: SPECIFY chocolate -

SPECIFY HOW WAS THE REACTION TREATED?

Drugs
Foods Chato lute .

Animals
Insects/ Other
Environmental Agents
 GUIDE TO
HISTORY TAKING
by NRC,RN

ACCIDENTS AND INJURIES:

TYPE OF INJURY WHEN TREATMENT COMPLICATIONS
nut .

last week .
tetanus receive .

PREVIOUS HOSPITALIZATIONS and SERIOUS ILLNESS: (e.g. HPN, DM, Myocardial

Infarction, CVA, Asthma, COPD, etc.)
DATE DIAGNOSIS TREATMENT/ SURGERY COMPLICATIONS

Asthma Mante luckiest .

levotelhuteton .

MEDICATIONS: Currently used Prescription Drugs (PD) or Over-the-counter (OTC)

Drugs:
MEDICATION HOW OFTEN PD or OTC
Once in one
month .

ask it Act she had any tent in the nooky

PAST SCREENING TESTS (e.g. Tuberculin, Pap smear): __________________________
OBSTETRICAL & MENSTRUAL HISTORY (for females):
GPTPALM? _______________
w/ Regular or Irregular Menstrual pattern? ___________
w/ or w/o use of Contraception? ___________
PSYCHIATRIC (for Psychiatric patients):
Illness and Time Frame: ______________________________________________
Diagnosis: _________________________________________________________
Hospitalizations: ____________________________________________________
Treatments: ________________________________________________________

E. FAMILY HEALTH ILLNESS HISTORY:

mother has asthma -

DISEASES YES NO DISEASES YES NO

Hypertension Obesity
Diabetes Mellitus Kidney problems
Cancer Tuberculosis
Allergies Alcoholism
Asthma Bleeding disorders
Arthritis Heart Diseases

TAKE NOTE: A Genogram may be done. pg 6 montell -

 GUIDE TO
HISTORY TAKING
by NRC,RN

F. LIFESTYLE AND HEALTH PRACTICES (Personal/Social): lsaneek

last month
.

canid
-

hamate 's B- Iue Mark

chicken
,
,

DESCRIPTION
.

Usual diet (foods & fluids) smoke } drink ? rent @ 12 mean

,
8 :Pmwr .

Exercise patterns No BDish

Sleep and Rest patterns SHE sleep I -6 -
.

Use of prohibited drugs and other *Already mentioned @ History of Present Illness IF coffee
black
substances (Caffeine,
✓ Nicotine,
Alcohol, Recreational drugs) halal liquor .
COMPLAINT* Drink cekhutud.li
Self-care responsibilities
Social activities for fun and
2-3 -
loiters water
relaxation
Social activities contributing to
society
work ?
Stressors in life and coping
strategies
Residency, Type of environment,
factory neck house ,
stressful life

neighborhood, environmental risks

Educational attainment *Already mentioned @ Demographic Data*
Occupation *Already mentioned @ Demographic Data*
Spiritual Beliefs
live bun glow house ,
in ventilated ,

G. REVIEW OF SYSTEMS FOR CURRENT HEALTH PROBLEMS: 3 rooms .

weight charge No -

SYSTEM OTHERS
Integumentary (✗) rash ( ) jaundice ( ) bruise ( ) mass
Head ( ) headache (✗
✗ ) dizziness ( ) trauma
high pitched
Ears ( ) tinnitus ( )
-
ear pain ( ) discharge ( ) dec. hearing
c
-

ringing
-

Nose ( ) coryza ✓-

( ) nasal congestion when wake up

-

Mouth & Throat ( ) bleeding

- ( ) sore throat ( ) hoarseness
-

d%ouyh
-

Respiratory ( ) hemoptysis ( ) dyspnea ( ) sputum production

- -
- .
morning
Cardiovascular ( ) chest pain ( ) palpitations How many pillows
-
-

Gastrointestinal (✓ ) abdominal pain ( ) vomiting ( ) bloatedness

-

(=)
LBM ( ) constipation change in bowel habit
-
.

Genitourinary ( ) dysuria ( ) nocturia ( ) polyuria ( ) incontinence

-

- -
-

Musculoskeletal ( =) muscle pain ( ) tenderness ( ) weakness - -

( ) decreased range of motion

Nervous ( ) seizures ( ) LOC ( ) tremors ( ) decreased sensorium
-

- -
-

Hematopoietic ( ) hematoma ( ) petechiae ( ) gross bleeding ( ) pallor

-
-
- -

Pain in eyes @ 11 pm -
-

TAKE NOTE: The Internal Medicine - PATIENT S HISTORY FORM on the next page is an actual
form that can be found n a patient s chart in the clinical setting.

-------------------------------------------- USE AT YOUR OWN RISK--------------------------------------------

 GUIDE TO
HISTORY TAKING
by NRC,RN

INTERNAL MEDICINE P A T I E N T S H I S T O R Y F O R M
CHIEF COMPLAINT: ________________________________________

HISTORY OF PRESENT ILLNESS:

_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________

REVIEW OF SYSTEMS:
SYSTEM OTHERS
Integumentary ( ) rash ( ) jaundice ( ) bruise ( ) mass
Head ( ) headache ( ) dizziness ( ) trauma
Ears ( ) tinnitus ( ) ear pain ( ) discharge ( ) dec. hearing
Nose ( ) coryza ( ) nasal congestion
Mouth & Throat ( ) bleeding ( ) sore throat ( ) hoarseness
Respiratory ( ) hemoptysis ( ) dyspnea ( ) sputum production
Cardiovascular ( ) chest pain ( ) palpitations
Gastrointestinal ( ) abdominal pain ( ) vomiting ( ) bloatedness
( ) LBM ( ) constipation
Genitourinary ( ) dysuria ( ) nocturia ( ) polyuria ( ) incontinence
Musculoskeletal ( ) muscle pain ( ) tenderness ( ) weakness
( ) decreased range of motion
Nervous ( ) seizures ( ) LOC ( ) tremors ( ) decreased sensorium
Hematopoietic ( ) hematoma ( ) petechiae ( ) gross bleeding ( ) pallor

PAST MEDICAL HISTORY

( ) Hypertension x __ years ( ) Myocardial Infarction ( ) ( ) Allergies
HBP ___ UBP ___ ( ) CVA ( ) ___ residual weakness ( ) Asthma
Meds: Meds: Last Exacerbation:
Meds:
( ) DM type __ x __ years ( ) Previous Hospitalizations: ( ) COPD
Meds: Meds:
( ) PTB Class __ on treatment w/ _______
( ) Others: Specify ____________
FAMILY HISTORY:
( ) Hypertension ( ) Allergies
( ) Diabetes Mellitus ( ) Asthma
( ) Cancer ( ) Others: Specify

PERSONAL & SOCIAL HISTORY:

( ) Smoker: ____ pack years ( ) Illicit drug use
( ) Alcoholic Beverage Drinker Occupation: ___________________________
( ) Others: Specify

________________________
Medical Resident

NAME: __________________________________________ AGE:___________ SEX: ______________

Attending Physician: ___________________________ Room No. __________ Hosp. No. __________
 PERTINENT PHYSICAL EXAMINATION FORM

WEIGHT: kgs. TEMP: C BP: mmHg HR: /min. RR: /min.

GENERAL APPEARANCE:
( ) Conscious ( ) Coherent ( ) Cardiorespiratory Distress Others: _________________________________________

SKIN: ( ) Pallor ( ) Lesions ( ) Jaundice ( ) Cold clammy Others: _________________________________________

HEENT: ( ) Icterisia ( ) Conjunctival pallor ( ) Tonsillarcongestion ( ) Neck vein engorgement ( ) CLAD Others: ____________

HEART: Apex beat _______ Rhythm __________ ( ) Murmur ( ) Heaves ( ) Lifts ( ) Thrills Others: _______________

LUNGS: ( ) Symmetric cheat expansion ( ) Retractions ( ) CBS ( ) Wheezes ( ) Crackles ( ) Rhonchi Others: _____________

ABDOMEN:
( ) Flat ( ) Normoactive bowel sounds ( ) Soft ( ) Tenderness ( ) Tympanitic
Quadrant: _______
( ) Distended ( ) Hypoactive bowel sounds ( ) Rigid ( ) Palpable ( ) Others
( ) Flabby ( ) Hyperactive bowel sounds ( ) Fluid wave Organomegaly
( ) Globular ( ) Others: _______________ ( ) Shifting dullness ( ) Stigmata of cirrhosis
( ) DRE

EXTREMITIES: ( ) pulses ________ ( ) edema ( ) tropic changes: ________________

( ) Others: ______________________

NEUROLOGIC EXAM:

GCS: E ________ V ________ M ________ CRANIAL NERVES:

LEVEL OF CONSCIOUSNESS:

ORIENTATION:

( ) APST ( ) FTNT ( ) Babinski

DTR's/ Motor/ Sensory

OTHER PERTINENT FINDINGS:

__________________________
Medical Resident

NAME: ______________________________________________ AGE: ____________ SEX: ______________

Attending Physician: ___________________________________ Room No. __________ Hosp. No. __________