Format for Clinical History Taking

This format is a general one. Additional information may be required in special cases like obstetric, infants, elderly etc.
It's an effort so that you don't miss out any section of history taking. All the best!

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Informant (relation to the patient):	Informant (relation to the patient):	Informant (relation to the patient):
Demographic information	Demographic information	Demographic information
Name
Age
Sex
Religion
Marital status
Address
Presenting complaints: In chronological order & patient’s language	Presenting complaints: In chronological order & patient’s language	Presenting complaints: In chronological order & patient’s language
Complaint in patient’s language	Duration (since how many days/ weeks/months/yrs.)	Duration (since how many days/ weeks/months/yrs.)
History of presenting complaints/illness (HOPI)	History of presenting complaints/illness (HOPI)	History of presenting complaints/illness (HOPI)
HOPC Review of systems (link/attached sheet):*while presenting the history, you need not mention all the systems. Just present the significant points, if any.	HOPC Review of systems (link/attached sheet):*while presenting the history, you need not mention all the systems. Just present the significant points, if any.	HOPC Review of systems (link/attached sheet):*while presenting the history, you need not mention all the systems. Just present the significant points, if any.
History of Past illness (past history)	History of Past illness (past history)	History of Past illness (past history)
Similar illness in past Any history of hospitalization Any history of surgery	Similar illness in past Any history of hospitalization Any history of surgery	Similar illness in past Any history of hospitalization Any history of surgery
Treatment history (present and past, including drug allergy)	Treatment history (present and past, including drug allergy)	Treatment history (present and past, including drug allergy)
Family history	Family history	Family history
History of similar illness in family: History of chronic diseases in the family e.g. Hypertension, CVD, IHD DM Tuberculosis History of consanguinity: Any known hereditary condition in the family: Any deaths in the family? Age and cause of death? Any other relevant history (depending on HOPI):	History of similar illness in family: History of chronic diseases in the family e.g. Hypertension, CVD, IHD DM Tuberculosis History of consanguinity: Any known hereditary condition in the family: Any deaths in the family? Age and cause of death? Any other relevant history (depending on HOPI):	History of similar illness in family: History of chronic diseases in the family e.g. Hypertension, CVD, IHD DM Tuberculosis History of consanguinity: Any known hereditary condition in the family: Any deaths in the family? Age and cause of death? Any other relevant history (depending on HOPI):
Occupational history (current and previous)	Occupational history (current and previous)	Occupational history (current and previous)
Dietary history	Dietary history	Dietary history
Personal history	Personal history	Personal history
Smoking Alcohol – estimate amount and if required ask CAGE questions Sexual Any change in bowel/urinary habit	Smoking Alcohol – estimate amount and if required ask CAGE questions Sexual Any change in bowel/urinary habit	Smoking Alcohol – estimate amount and if required ask CAGE questions Sexual Any change in bowel/urinary habit
Menstrual history (in females)	Menstrual history (in females)	Menstrual history (in females)
Age at menarche Menstrual pattern Cycle length Duration of flow Amount of flow Dysmenorrhea Inter menstrual bleeding	Age at menarche Menstrual pattern Cycle length Duration of flow Amount of flow Dysmenorrhea Inter menstrual bleeding	LMP Age at menopause (if applicable) Menopausal symptoms Contraception use (if applicable)
Obstetric history (in females)	Obstetric history (in females)	Obstetric history (in females)
Number of pregnancies and their outcome Describe each pregnancy: Full term/preterm Mode of delivery Any complications Maternal Neonatal	Number of pregnancies and their outcome Describe each pregnancy: Full term/preterm Mode of delivery Any complications Maternal Neonatal	Number of pregnancies and their outcome Describe each pregnancy: Full term/preterm Mode of delivery Any complications Maternal Neonatal
Social history/living circumstances	Social history/living circumstances	Social history/living circumstances
Possible relevant factors in and around the house and work place Travel history if relevant Sexual history if relevant Pets: Any other	Possible relevant factors in and around the house and work place Travel history if relevant Sexual history if relevant Pets: Any other	Possible relevant factors in and around the house and work place Travel history if relevant Sexual history if relevant Pets: Any other

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Additional headings for different types of case may be needed. Some are listed below. However, a detailed history format may be found for individual type of case

As you gain experience, you would spontaneously know which specific symptoms to ask for, to rule out or confirm certain disorders. However, the beginners can check out all the systems listed in the table below.

If there is any positive response to any of these, you have to ask further questions which raise or lessen the probability of certain diagnoses. This new information has to be added to the HOPI or past illness as relevant.

References:

1. R Alagappan. Manual of Practical Medicine. 4th ed. New Delhi. Jaypee Brothers Medical Publishers, 2011

2. Graham Douglas, Fiona Nicol, Colin Robertson. HISTORY TAKING AND GENERAL EXAMINATION. In Macleod’s Clinical Examination. 13th ed. Edinburgh. Churchil Livingstone Elsevier, 2013: 5 – 354

3. Michael Glynn, William M. Drake. Doctor and patient: General principles of history taking .In HUTCHISON’S CLINICAL METHODS. 24th Ed. London. Elsevier, 2018: 20 – 31

4. Bowdler, N, Elson, M, Glob. libr. women's med., (ISSN: 1756-2228) 2008; DOI 10.3843/GLOWM.10003

5. Geriatric Clinico-Social Case in Community Medicine

6. Makhija, S. & Tiwari, P. Indian J Pediatr (2018) 85: 738. https://doi.org/10.1007/s12098-017-2388-z

7. Diane Sacks, Michael Westwood, 2003. An approach to interviewing adolescents. Paediatr Child Health Vol 8 No 9 November 2003: 554-556

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