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History taking is an art and has to be practiced each time you see a patient. Below is the format

The History

1) Chief complaints
Should be in descending order of time of symptoms

2) History of presenting illness

  • Mode of onset- Acute/ sub acute/ chronic
  • Progress
  • Duration
  • Appetite
  • Loss of weight/ fatigue
  • Bladder/ bowel

3) Past history  

  • Rheumatic fever
  • Tuberculosis
  • Malaria
  • Jaundice
  • Systemic hypertension
  • Diabetes
  • Blood transfusions
  • Hospital Admissions

4) Birth History

  • Gestation at birth
  • Complications at birth
  • Immunization

5) Allergy history

  • Allergens
  • Medications used
  • Severity of allergy

6) Family History

  • History of similar problems in the family
  • Pedigree tree(history of at least 3 consequent generations)
  • Sudden deaths in the family
  • Consanguinity
  • Environmental factors- like smoking in the family in the case of wheeze.

7) Treatment history

  • Any treatments so far
  • Any surgical interventions
  • Any medications being used
  • Compliance to the medications

8) Menstrual history/ Obstetric history

  • Menarche
  • Duration of periods
  • Dysmennorhoea/ Amenorrhoea/ Irregularities
  • Last Menstrual date
  • Sexual activity

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