THEMEDPRACTICALEXAM.COM

PROFORMA FOR HISTORY TAKING

themedpracticalexam.com

I. BIODATA

  • Name: [Patient's Full Name]

  • Age: [ ] yrs | Gender: [M/F/Other]

  • Residence: [Address/City, State]

  • Education: [Level] | Occupation: [Job]

  • Date of Admission: [DD/MM/YYYY]

  • Date of Exam: [DD/MM/YYYY]

  • Informant: [Self/Relation] | Reliability: [Reliable/Fairly/Unreliable]

II. PRESENTING COMPLAINTS (C/C)

  • Chronological order, patient's words:

    1. [Complaint 1] x [Duration]

    2. [Complaint 2] x [Duration]

    3. [Complaint 3] x [Duration] ...

III. HISTORY OF PRESENTING COMPLAINTS (HPC)

  • Elaborate on each C/C in detail.

  • For each symptom, cover:

    • Onset: (Sudden/Gradual, Date/Time, Precipitating)

    • Duration: (Continuous/Intermittent, Frequency)

    • Progression: (Worsening/Improving/Static?)

    • Aggravating/Relieving Factors: (What makes it worse/better?)

    • Associated Symptoms: (Other symptoms with it?)

    • Current status of the symptom

  • Include relevant positive and negative symptoms for each system involved.

    • General: Fever, weight change, fatigue, night sweats.

    • CVS: Chest pain, palpitations, shortness of breath on exertion, orthopnoea, PND, ankle swelling.

    • Resp: Cough, sputum, hemoptysis, breathlessness, wheeze.

    • GI: Abdominal pain, N/V, jaundice, bowel habits.

    • GU: Dysuria, frequency, hematuria, flank pain.

    • Neuro: Headache, dizziness, seizures, weakness, numbness.

    • MSK: Joint pain/swelling/stiffness, back pain.

    • Endocrine: Polydipsia, polyuria, polyphagia, heat/cold intolerance.

    • Skin: Rashes, itching.

IV. PAST HISTORY

  • Past Medical: Similar complaints? DM, HTN, CAD, Asthma, TB, Jaundice, Stroke, Epilepsy, Renal/Thyroid disease. Blood Transfusion?

  • Past Surgical: Type, date, reason, outcome.

  • Childhood Illnesses: Measles, Mumps, Rubella, Chickenpox, Rheumatic Fever.

  • Immunization: (e.g., Tetanus, COVID-19).

V. FAMILY HISTORY

  • Similar/Chronic illness in 1st-degree relatives (Parents, Siblings, Children).

  • Causes of death in immediate family.

  • Consanguinity?

VI. PERSONAL HISTORY

  • Diet: (Veg/Non-veg, regularity).

  • Sleep: (Pattern, hours).

  • Bladder/Bowel Habits: (Frequency, dysuria, constipation/diarrhea).

  • Addictions:

    • Smoking: Type, quantity, duration (pack-years).

    • Alcohol: Type, quantity, frequency, duration.

    • Tobacco Chewing/Others: Quantity, duration.

  • Drug History (Current Meds): Name, Dose, Freq, Route, Duration, Reason. Drug Allergies (specify drug & reaction). Compliance.

  • Menstrual History (Females): Menarche age, Cycle regularity/duration/flow, LMP. Dysmenorrhea/Menorrhagia/Amenorrhea. Contraceptive use.

  • Obstetric History (Females): G/P/A/L. Complications.

VII. SOCIOECONOMIC HISTORY

  • House Type: (Kutcha/Pucca, ventilation).

  • Water/Sanitation: (Source, type).

  • Family Comp.: (Members, dependents).

  • Income: (Approx. monthly).

  • Occupational Exposure: (Dust, fumes, chemicals).

  • Stressors: (Financial, family, work).

VIII. SUMMARY OF HISTORY

  • Concise summary of key points: Demographics, Chief Complaints, main HPC points, significant positives from Past, Family, and Personal History.

  • Example: "Mr. [Name], [Age]y, [Gender] from [Place], [Occupation], admitted on [Date] with [C/C 1] x [Dur.], [C/C 2] x [Dur.], associated with [Key associated symptoms]. H/o [Relevant Past Hx, e.g., DM x 10y]. No significant FH. Smoker of 20 pack-years. No known drug allergies."