MEDICAL HISTORY CHECKLIST Samuel Aguazim ( MD)

1. Identification Information: Date the history was taken, Name of patient, Medical record number( If any) Age and Sex Place of birth Marital Status Current occupation

2. Source of information: Is information given by patient, member of family Or friend Who referred the patient

Chief Complaint: A brief statement in patients own words, the reason why he/she is seeking medical attention. Elicit with open ended question: what brings you here

History of present Illness: Detailed and chronological account of the patients current problem Onset of symptoms Location of symptoms Character of symptom Radiation of pain or Sensation Aggravating Factors Relieving factors Course of symptoms ( getting better or worsening daily) Effect on daily life Did the patient have similar complaints in the past, If yes 1. when, where and by whom 2. what investigations have been done and the results 3. what was the diagnosis at that time?

5. Past Medical History: Any childhood illness Measles, mumps, rubella, chicken pox, diphtheria, Tetanus, Rheumatic fever Immunizations: E.g.: Last tetanus booster which should be received every 10 years

5. Past Medical History: Adult Illnesses: Significant past, chronic( Like HTN, DM, Bronchial Asthma etc) Any non traditional health care if the patients is seeking Surgeries Injuries Hospitalizations Allergies Eg: food, medications and dust and pollen Current Medications Any prescription and non prescription medication if the patient is taking like vitamins and OTC

5. Past Medical History: Habits Exercise history, type of exercise and frequency Substances: Tobacco, Alcohol, Caffeine, Recreational Drugs, Safety (like seat belts and smoke detectors)

5. Past Medical History: Sleep Patterns: Any sleep problems, if yes 1. When the patient goes to bed and if he /she experiences any trouble falling asleep 2. If there is frequent wakening during night 3. Any early morning awakening (earlier than usual)

Diet Any dietary deficiencies that could relate to patients current disorder Any diet Restrictions

Family History: Any significant medical conditions in the family members.

7. Psychosocial History: How is the patients current illness affecting his/her daily routine life? How will the treatment affect his/her daily life Know the patients Support System Alone or with family or friends Who can care for the patients in times of need How far is the patient from site of health care How will short term disability or absence affect his or her occupation, family integrity