1. Chief Complaint :Main problem
with duration, origin& relation with place, diet, food, occupation with detailed symptoms.
2. History of present complaints :
All
details about the history of the present
complaint. Onset of symptoms and the
factors relieving the symptoms (Rest,
exercise, season, place, medication )
3. History of past
illness
: All details about the
previous illnesses you have suffered from (infections,
injuries, systemic diseases) along with the age
of onset & duration).
4.Treatment history :Tell the diagnosis if already known. Describe the
treatments you underwent and medicaments /
therapies you are undergoing now. You should
describe the order of use of the medicines and
the response to the treatment.
5. Gynecological History :
Please cover the following
points in your information.
*Age of menarche.
*Regularity of cycle
*Flow of cycle (Normal, scanty or excess).
Are you taking any contraceptive pills.
*Age of menopause
*Discomforts with menses( pain, vomiting, giddiness).
*Any abnormal discharge like leucorrhoea.
*Details of pregnancies & type of delivery.
6.
Personal history :
a. Atmosphere at the
job, family or the society.
Does your disease or symptoms have any relation
to the above?
b. Bowel habits.
Time of the day
when you usually go for bowel movements.
Frequency
Colour of stool
Consistency
Whether foul smelling
Regular or irregular ?
associated with pain, burning sensation or
itching ? any protrusion ?, blood spots
or bleeding?
c.
Urine habits.
How many times you go for urination( in day & in
night). Associated with burning or not?
d.Allergy
Towards
particular food, medicines, dust, climate or
others
e.Dietry
habits
Vegetarian/Eggetarian or non-vegetarian)
Appetite (Good/excessive or low)Addiction (Tea/Alcohol/smoking/drugs)
f.
Sleep habits
Good & Sound/Irregular/Disturbed
g. Working habits
Sedentary/Touring/manual work
h. Influence of climate or environment.
Describe briefly the type of climate and
environment in which you live ? Is there any
relationship to the climatic condition? Do these
symptoms increase or decrease in a particular
climate or environment ?
7. Any other information that
you feel might help in making a proper
diagnosis.