HISTORY TAKING CHECKLIST

N
o.
A.
1.
2.

Activity
Establishing Rapport:
Greets patients / Introduces self
Asks patient:
Name:
Location:

Age:

Race:

3.

Chief complaint:

C.
4.
5.

History of presenting problem:

Site: Be specific
Duration: Since when?
On/off?
Especially during when?
Onset:
Spontaneous, sudden, insidious onset
Progression:
Gradually decreasing/ increasing amount of stool/vomit/pain/mass
Characteristic:
Stool: watery/semisolid/ solid mixed with mucus/blood
Pain: stabbing/burning/colicky/on& off
Radiation:
Associated symptoms
any other complaints
besides the chief complaint
US
Flow and stream: lancar tak
GIT
Urgency: berlari ke toilet, boleh tahan
Diarrhoea
kencing tak?
Constipation
Dribbling & distention/retention: lepas
Loss of appetite
kencing, ada menitis tak?
Nausea
Retention: rasa penuh tapi tak boleh
keluar
Vomiting
Incomplete emptying: tak lawas
Blood in stool
Incontinence: terkucil, tiba2 terkencing
Mucus in stool
waktu terbatuk, terbersin
Pain in abdomen

Smell: (ketone fruity, albumin foul)

Weight loss
Colour: what colour? (DONT give
Lethargy
answer)
Abdominal distension
Others: such as pus at the beginning of
micturition

6.
7.
8.
9.
10
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11
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12
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13
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Precipitating factor: Any change in diet, any infection, any stressful life
event
Aggravating factor: Any particular food item, outside food, stress,
movement
Relieving factors: skipping meal, light diet

D.
14

Systemic review:
a) CVS: Palpitation, SOB, pedal edema, chest pain, nocturnal dyspnoea,

E.
15
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16
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17
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18
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F.
19
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G.
20
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H.
21
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orthopnoea
b) Respiratory: Cough, SOB, chest pain, wheezing, sputum
c) CNS: Loss of consciousness, seizures, headache, vomiting, motor
weakness, sensory loss
d) Urinary: Micturition, pain in loin, pain in urethra
e) GIT: LOA, LOW, Nausea, Vomiting, Diarrhoea, pain in abdomen,
Constipation, Hematemesis
f) Reproductive: Vaginal/ urethral discharge, menstruation, libido, breast
symptoms
g) Musculoskeletal: Muscle/bone/joint pain, myalgias, limb/spine
deformity, gait
h) Endocrine: Growth, secondary sexual characteristics
i) Skin: Pigmentation, rashes, ulcers
j) Hematology: Bleeding disorder, tiredness, paleness, recurrent infections
Past History:
Past medical history:
Pernah sakit macam ni sebelum ni?
Pernah sakit apa-apa?
Pernah masuk hospital?
Past surgical history:
Pernah masuk hospital untuk operation?
History of allergy:
To any food/drug/anything
Drug history (including supplements & traditional medicines)
Family history:
Asks about family history of chronic illnesses
(Maternal side, paternal side, parents, siblings, children)
Anyone pernah sakit macam ni?
Anyone sakit chronic: diabetes, hypertension, heart disease, stroke, blood
disorder, ca, renal
When, where, complication?
Anyone under medication for anything?
Social / personal history:
a) Occupation: Nature of job, income, post
b) Social relationships: Friends, relatives, relationship
c) Diet: Food preference
d) Sleep pattern: Sleep hours, quality of sleep
e) Smoking: Smoking habits and duration, type of cig
f) Alcohol: Alcohol habits and type and amount of alcohol
g) Sexual history:( just nice to know)
Are you currently in relationship?
How long have u been with your partner?
Are you sexually active?
Have you had any other sexual partners in the last 12 months?
When did you last have sex?
Do you use barrier contraception?
Have u had STI?
h) Overseas travelling: Recent travels to other countries, where?
How long? What did you do there?
Menstrual history:
a) Menarche: Age menstruation started
b) Interval: Regularity and number of days from 1st day of one
menstruation to 1st day of next menstruation
c) Duration: Number of days menstruation lasts

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22
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d) Dysmenorrhea: Presence or absence of dysmenorrhea

e) Cycle: Flow: Estimate of amount of blood flow i.e. number of pads used
daily
f) Last menstrual Period (LMP): Date of 1st day of last menstrual period
Obstetric history:
Gravida: Number of total pregnancies including current (If any)
Para: Number of alive children plus number of abortions