THEMEDPRACTICALEXAM.COM
PROFORMA FOR HISTORY TAKING
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:
[Complaint 1] x [Duration]
[Complaint 2] x [Duration]
[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."