COMPREHENSIVE MEDICAL HISTORY TAKING

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1. IDENTIFICATION DATA

• Name:
• Age:
• Sex:
• Occupation:
• Address:
• Marital Status:
• Date of Admission / Consultation:
• Informant (and reliability):

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2. CHIEF COMPLAINT(S)

• Presenting symptom(s):
  • Nature of symptom:
    • Pain (burning, dull, throbbing, sharp, colicky, cramping)
    • Swelling (pitting/non-pitting, localized/generalized)
    • Fever (low-grade, high-grade, intermittent, continuous, remittent)
    • Cough (dry, productive, hemoptysis, barking)
    • Others (as per specific system)
• Duration of each complaint:
• Sequence of onset:
• Severity of each:
• Effect on activities of daily living:
• Day/night variation:

Associated Complaints

• Complaint:
• Duration:
• Temporal association with chief complaint:
• Significance or complications:

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3. HISTORY OF PRESENT ILLNESS

A. Onset

• Sudden / Gradual
• Exact time/date of onset
• Initial symptom noticed

B. Progression

• Static / Progressive / Relapsing-remitting
• Episodic or continuous
• Speed of worsening (rapid/slow)

C. Characterization of Each Complaint

• Location: Precise anatomical site
• Radiation: Yes/No; if yes, where?
• Type of pain:
  • Dull, sharp, throbbing, burning, stabbing, colicky, constricting
• Severity: VAS scale (1-10)
• Frequency: Constant/intermittent
• Diurnal variation: Morning, night, throughout

D. Triggering Factors

• Activity related: Walking (e.g., claudication, sciatica)
• Position-related: Lying down (e.g., orthopnea), bending
• Meals: After fatty meals (e.g., biliary colic)
• Environmental: Cold air (e.g., asthma), dust, pollen
• Emotional stress
• Menstrual cycle

E. Relieving Factors

• Rest
• Medication
• Change in posture
• Food or fasting
• Home remedies

F. Similar Complaints in Past

• Yes / No
  • If yes:
    • Number of episodes:
    • Duration and frequency:
    • Similarity in severity and presentation:
    • Resolution and intervention used:

G. Treatment Taken

• Type of healthcare approached
• Investigations done:
• Medications used:
• Any improvement:

H. Functional Impact

• Impaired mobility
• Sleep disturbance
• Absenteeism from work/school
• Dependence on others

I. Systemic Correlation

• Respiratory: Cough, breathlessness, sputum (mucoid/purulent), hemoptysis, wheeze
• Cardiovascular: Chest pain (exertional/rest), palpitations, syncope, orthopnea, PND
• Gastrointestinal: Nausea, vomiting, appetite, heartburn, bloating, bowel habits
• Neurological: Headache, dizziness, weakness, numbness, seizures, vision/hearing issues
• Musculoskeletal: Joint pain/swelling, morning stiffness, muscle cramps, deformity
• Genitourinary: Burning micturition, urgency, hesitancy, frequency, nocturia, hematuria
• Skin: Rashes, itching, dryness, lesions, ulcers

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4. PAST HISTORY

A. Medical History

• Hypertension
• Diabetes Mellitus
• Asthma / COPD
• Tuberculosis
• Epilepsy
• Liver disorders (Hepatitis, cirrhosis)
• Kidney disorders (stones, CKD)
• CAD / MI
• Stroke / TIA
• Psychiatric illness

B. Surgical History

• Past surgeries:
  • Type
  • Indication
  • Year
  • Complications (if any)

C. Hospitalizations

• Reason
• Duration
• Treatment given

D. Blood Transfusions

• Yes / No
  • If yes:
    • Date
    • Number of units
    • Reason
    • Reactions

E. Drug History

• Current medications:
• Past long-term medications:
• Self-medication habit:

F. Allergy History

• Drug allergies (e.g., penicillin, sulpha)
• Food allergies (e.g., nuts, seafood)
• Environmental (e.g., dust, pollen, latex)
• Type of reaction: rash, breathing difficulty, anaphylaxis

G. Immunization Status

• Childhood immunizations
• Tetanus, Hepatitis B, COVID vaccine status

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5. PERSONAL HISTORY

A. Dietary Pattern

• Vegetarian / Non-vegetarian / Mixed
• Appetite:
  • Normal / Increased / Decreased
  • Sudden changes
  • Cravings or aversions
• Recent weight changes:
  • Weight gain / Weight loss (intentional or unintentional)
• Fluid intake: adequate/inadequate

B. Bowel Habits

• Frequency: daily/alternate days/constipation/diarrhea
• Consistency:
  • Formed, hard, loose, watery, ribbon-like, greasy, clay-colored
• Blood/mucus: Yes/No
• Any incontinence or urgency

C. Bladder Habits

• Frequency: polyuria/oliguria
• Urgency, hesitancy, dribbling
• Nocturia: present/absent
• Burning micturition
• Hematuria

D. Sleep Pattern

• Duration: <4h / 4–6h / 6–8h / >8h
• Quality:
  • Restful, disturbed, difficulty initiating, early waking
• Sleep disorders: insomnia, hypersomnia, snoring, apnea

E. Addictions

• Smoking:
  • Type (bidi/cigarette), packs/day, years
• Alcohol:
  • Type, quantity, frequency, binge pattern
• Tobacco (chewing, gutka, pan): frequency and duration
• Others: cannabis, opioids

F. Sexual History

• Marital status
• Age at first intercourse
• Number of partners
• Contraceptive use
• Risk behavior or STDs

G. Menstrual History (Females)

• Age at menarche
• Cycle regularity, interval, duration
• Amount of bleeding (scanty/moderate/heavy)
• LMP
• Menopause (if applicable): age, symptoms

H. Obstetric History

• Gravida, Para, Abortion, Living children (G-P-A-L)
• Mode of deliveries
• Complications (e.g., PPH, eclampsia)

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6. FAMILY HISTORY

• Similar illness in family
• History of hereditary diseases (e.g., hemophilia, thalassemia)
• Chronic illnesses (DM, HTN, TB, asthma, CAD, psychiatric illnesses)
• Consanguinity

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7. SOCIOECONOMIC HISTORY

• Monthly income / family income bracket
• Type of housing (pucca/kachcha, overcrowding)
• Water and sanitation facilities
• Education level
• Occupation and occupational exposures
• Dependents and social support

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8. GENERAL EXAMINATION

• General condition: Conscious/Oriented
• Build & nourishment: Ectomorphic/Mesomorphic/Endomorphic
• Pallor
• Icterus
• Cyanosis
• Clubbing (Grade I–IV)
• Lymphadenopathy: Site, size, tenderness, mobility
• Edema: Pitting/non-pitting, localized/generalized
• Height, Weight, BMI
• Vitals:
  • Pulse (rate, rhythm, volume, character)
  • Blood pressure (sitting, supine, standing)
  • Temperature
  • Respiratory rate
  • SpO2 (room air)

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9. SYSTEMIC EXAMINATION (To follow history and general examination)

• Respiratory System
• Cardiovascular System
• Abdomen (Gastrointestinal)
• Central and Peripheral Nervous System
• Musculoskeletal System
• Genitourinary System

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