SECTION 1: IDENTIFICATION DATA
□ Name
□ Age
□ Sex
□ Hospital Registration Number
□ IP / OP Number
□ Date and Time of Registration
□ Date and Time of Admission
□ Referred From
□ Department
□ Consultant in Charge
□ Unit
□ Address
□ Contact Details
□ Occupation
□ Education Level
□ Socioeconomic Status
□ Marital Status
□ Insurance Details
□ Informant Name
□ Relationship to Patient
□ Reliability of Informant: □ Good □ Fair □ Poor
SECTION 2: CHIEF COMPLAINTS
Document in patient’s own words with duration.
□ Fever – duration
□ Pain – site – duration
□ Swelling – site – duration
□ Breathlessness – duration
□ Chest pain – duration
□ Cough – duration
□ Palpitations – duration
□ Syncope – duration
□ Vomiting – duration
□ Abdominal pain – duration
□ Altered bowel habits – duration
□ Burning micturition – duration
□ Reduced urine output – duration
□ Limb weakness – duration
□ Seizures – duration
□ Headache – duration
□ Joint pain – duration
□ Skin rash – duration
□ Weight loss – duration
□ Weight gain – duration
□ Fatigue – duration
□ Any other complaint
For each complaint clarify:
Onset
□ Sudden
□ Acute
□ Subacute
□ Insidious
Course
□ Progressive
□ Static
□ Relapsing
□ Episodic
□ Seasonal
Severity
□ Mild
□ Moderate
□ Severe
□ Disabling
□ ICU requiring
Aggravating factors
□ Exertion
□ Food
□ Posture
□ Stress
□ Cold exposure
□ Drugs
□ Infection
Relieving factors
□ Rest
□ Medications
□ Position change
□ Food
Diurnal variation
□ Morning
□ Evening
□ Night predominance
□ None
SECTION 3: HISTORY OF PRESENTING ILLNESS
Chronological detailed narrative
Initial symptom
Progression pattern
Functional limitation
Associated symptoms
Red flag events
Previous consultations
Investigations done
Treatment taken and response
Hospital admissions
ICU admissions
Procedures done
SECTION 4: SYSTEM-WISE SYMPTOM
CARDIOVASCULAR
□ Chest pain – character – radiation – duration
□ Dyspnea – NYHA grading
□ Orthopnea
□ Paroxysmal nocturnal dyspnea
□ Palpitations
□ Syncope
□ Pedal edema
□ Claudication
□ Cyanosis
RESPIRATORY
□ Cough – dry / productive
□ Sputum – color – quantity
□ Hemoptysis
□ Wheeze
□ Dyspnea
□ Pleuritic pain
□ Tuberculosis contact
□ Occupational exposure
□ Smoking history
GASTROINTESTINAL
□ Dysphagia
□ Odynophagia
□ Reflux
□ Abdominal pain – site – relation to food
□ Vomiting
□ Hematemesis
□ Melena
□ Jaundice
□ Pruritus
□ Altered bowel habits
□ Tenesmus
□ Weight loss
GENITOURINARY
□ Dysuria
□ Frequency
□ Urgency
□ Nocturia
□ Hematuria
□ Flank pain
□ Reduced urine output
□ Frothy urine
□ Incontinence
NERVOUS SYSTEM
□ Headache
□ Seizures
□ Loss of consciousness
□ Limb weakness
□ Numbness
□ Speech difficulty
□ Visual disturbance
□ Memory impairment
□ Tremors
□ Gait imbalance
ENDOCRINE
□ Weight gain
□ Weight loss
□ Heat intolerance
□ Cold intolerance
□ Polyuria
□ Polydipsia
□ Polyphagia
□ Skin pigmentation
□ Striae
□ Voice change
□ Menstrual irregularities
MUSCULOSKELETAL
□ Joint pain
□ Morning stiffness – duration
□ Joint swelling
□ Redness
□ Deformity
□ Back pain
□ Muscle weakness
□ Muscle pain
HEMATOLOGICAL
□ Pallor
□ Easy bruising
□ Bleeding gums
□ Petechiae
□ Lymph node swelling
□ Recurrent infections
DERMATOLOGICAL
□ Rash
□ Photosensitivity
□ Oral ulcers
□ Alopecia
□ Skin tightening
□ Nodules
□ Ulcers
SECTION 5: PAST HISTORY
□ Hypertension – duration – control
□ Diabetes – duration – control
□ Coronary artery disease
□ Stroke
□ Chronic kidney disease
□ Chronic liver disease
□ Asthma
□ Tuberculosis
□ Thyroid disorder
□ Autoimmune disease
□ Malignancy
□ Surgery
□ Blood transfusion
□ ICU admission
SECTION 6: DRUG HISTORY
□ Antihypertensives
□ Antidiabetics
□ Antiplatelets
□ Anticoagulants
□ Steroids
□ Immunosuppressants
□ Statins
□ Hormonal therapy
□ Antiepileptics
□ Alternative medicine
Compliance
□ Regular
□ Irregular
□ Poor
Adverse drug reactions
□ Yes
□ No
SECTION 7: FAMILY HISTORY
□ Hypertension
□ Diabetes
□ Stroke
□ Sudden cardiac death
□ Genetic disorders
□ Autoimmune disease
□ Malignancy
□ Consanguinity
SECTION 8: PERSONAL HISTORY
Diet
□ Vegetarian
□ Mixed
□ High salt
□ High fat
Appetite
□ Normal
□ Reduced
□ Increased
Sleep
□ Adequate
□ Disturbed
Bowel
□ Regular
□ Constipation
□ Diarrhea
Bladder
□ Normal
□ Abnormal
Addictions
□ Smoking – pack years
□ Alcohol – quantity – duration
□ Tobacco
□ Substance abuse
Physical activity
□ Sedentary
□ Moderate
□ Heavy
Occupational hazards
SECTION 9: GENERAL EXAMINATION
Built
□ Well built
□ Moderately built
□ Poorly built
Nourishment
□ Good
□ Moderate
□ Poor
□ Obese
□ Cachectic
Hydration
□ Adequate
□ Mild dehydration
□ Moderate dehydration
□ Severe dehydration
Pallor
□ Absent
□ Present – mild
□ Moderate
□ Severe
Location
□ Conjunctiva
□ Nail beds
□ Palmar creases
Icterus
□ Absent
□ Present
Location
□ Sclera
□ Skin
□ Hard palate
Cyanosis
□ Absent
□ Central
□ Peripheral
Location
□ Lips
□ Tongue
□ Nail beds
Grade
□ Mild
□ Moderate
□ Severe
Clubbing
□ Absent
□ Grade I
□ Grade II
□ Grade III
□ Grade IV
Lymphadenopathy
□ Absent
□ Present
Site
□ Cervical
□ Axillary
□ Inguinal
□ Generalized
Size
□ <1 cm
□ 1–2 cm
□ >2 cm
Tenderness
□ Present
□ Absent
Consistency
□ Soft
□ Firm
□ Hard
Mobility
□ Mobile
□ Fixed
Edema
□ Absent
□ Present
Type
□ Pitting
□ Non pitting
Grade
□ 1+
□ 2+
□ 3+
□ 4+
Location
□ Feet
□ Ankles
□ Legs
□ Sacral
□ Periorbital
□ Generalized
Vital Signs
Pulse – rate – rhythm – volume – character
Blood pressure – right arm – left arm – supine – standing
Respiratory rate
Temperature
SpO2
BMI
SECTION 10: SYSTEMIC EXAMINATION
Cardiovascular
Inspection
Palpation
Percussion
Auscultation
Peripheral pulses
Respiratory
Inspection
Palpation
Percussion
Auscultation
Abdominal
Inspection
Palpation
Percussion
Auscultation
Neurological
Higher mental functions
Cranial nerves
Motor system – bulk – tone – power
Reflexes
Sensory system
Cerebellar signs
Gait
Musculoskeletal
Inspection
Palpation
Range of motion
Deformities
SECTION 11: FUNCTIONAL ASSESSMENT
□ NYHA
□ Glasgow Coma Scale
□ Modified Rankin
□ Child Pugh
□ MMSE
□ ECOG
□ DAS28
SECTION 12: INVESTIGATIONS
Laboratory
□ Complete blood count
□ ESR
□ CRP
□ Liver function
□ Renal function
□ Electrolytes
□ Blood sugar
□ HbA1c
□ Lipid profile
□ Thyroid profile
Imaging
□ X ray
□ Ultrasound
□ CT
□ MRI
□ Echocardiography
□ ECG
Special tests as per system
□ Autoimmune markers
□ Tumor markers
□ CSF analysis
□ Biopsy
□ Genetic testing
SECTION 13: PROVISIONAL DIAGNOSIS
SECTION 14: DIFFERENTIAL DIAGNOSIS
1
2
3
SECTION 15: FINAL DIAGNOSIS WITH STAGING
SECTION 16: MANAGEMENT PLAN
□ Medical management
□ Surgical management
□ Interventional
□ ICU care
□ Rehabilitation
□ Lifestyle modification
□ Follow up schedule
SECTION 17: PROGNOSIS
□ Favorable
□ Guarded
□ Poor
