Health History And physical Examination Format (Guideline)



a.       Introduction:-
b.       Patient’s profile :
·         Name :
·         Hospital no :
·         Age………..Years
·         Gender
·         Address
·         Religion: Hindu/Muslim /Christian /Sikh /any other
·         Marital status : married /singal/widow
·         Date and time of admission:
·         Ward /bed no:
·         Diagnosis : Medical/ Surgical
·         Date of surgery (if any):
·         Informant:
c.       Chief complaint with duration (on the day of admission X duration):
d.       History of present illness: Presenting signs and symptoms/ onset/duration/ progress/ aggravating and relieving factors/ treatment taken.
e.       History of past illness:
f.        Family history ( 3 generation genogram with key )
·         Type: joint /nuclear :
·         Number of members :
·         Any illness : TB, DM , HT ,Hereditary illness /any other
g.       Socio economic status :
    i.      Social Aspect :
·         Who makes decision on health matters
·         Support system
·         Neighbourhood relationship
·         Involvement in social activities , if applicable.
      ii.    Economic status
·         Education
·         Occupation
·         Family income /month
·         Type  of house and ventilation
·         Toilet facility
·         Water source
h.       Nearest health care facilities : PHC/ clinics / hospitals / others
i.        Personal history :
·         Immunization history
·         Dietary history : vegetarian / Non vegetarian
                                No . of Meals /day
                Food preference
·         Fluid intake ……………..glasses/day
·         Beverages………………..glasses /day
·         Personal hygiene : Oral Hygiene : Frequency
Bath :frequency
·         Sleep and rest :
·         Hours at night
·         Drugs used for sleeping
·         Uninterrupted /interrupted
·         Day time naps ……….hours /day
·         Activity and exercise :
Daily walking / any other
Nature of work : sedentary /mild /moderate/heavy
·         Habits/ hobbies:
                                                Tobacco / alcohol / drug/ any other
·         Elimination :
Bowel : Frequency
Regular /irregular /constipation
Bladder : Frequency at night /day
j.        Marital / sexual history:
·         Married or widow /widower
·         Unmarried or unmarried mother
·         Spouse general health ; good /fair/bad
·         Spouse job status : working / not working
·         Staying together : yes /no
·         Relationship with spouse : satisfactory / unsatisfactory
k.       Female :
Menstrual history : age at menarche / duration and frequency / any irregularities
Age at menopause / post-menopausal problem , if any specify
l.        Male :

Anything specific



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item Health History And physical Examination Format (Guideline)
Health History And physical Examination Format (Guideline)
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