Patient history
1. Personal data
• name, address, date of birth, referring physician, next of kin
2. plaint
3. Social status
• occupation, family, daily function, …
4. Medical history
a) Family illnesses – parents, siblings, children
b) Prior illnesses – in chronologic order. Duration, treatment, complications
c) Present illnesses – onset, symptoms, course of symptoms, present status
5. Review of systems
• Skin, head, eyes, ears, nose, mouth, throat, respiratory tract, cardiovascular +
lymphatics, GIT, urinary tract, genitalia, otor, nervous, psychological
state, endocrine, allergies
• Natural functions: voiding, defecation, eating habits/weight changes, sleep
6. Stimulantia
• o, alcohol, drug abuse etc.
7. Medication
• All drugs, strength, doses, duration
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