General Data: name, age, gender, occupation, marital status (S., M., S., D.)
Chief Complaint: weakness, malaise, chills, fever, sleep, pain, headache, appetite, weight, stomach and bowels, nausea and vomiting, diarrhea, urine, genitalia, neuropsychiatric disorders, respiration, shortness of breath, bleeding or discharge, etc.
Present Illness: onset (date, mode), duration before present entry, exciting cause and
environmental influences, prodromal symptoms, general symptoms, course or progress (location, duration, severity, continuity, intermission, radiation, treatment), aggravating and alleviating factors, loss of weight, appetite and strength, sleep, bowel movement, frequency of urination, menstruation, etc.
1. Former places of residence, previous state of health (robust, delicate), experience with similar
disease, immunity to infectious diseases.
2. Previous illness: measles, mumps, chicken pox, pertussis, influenza, scarlet fever, diphtheria,
typhoid fever, bronchitis, pneumonia, encephalitis, meningitis, tetanus, poliomyelitis, dysentery,
cholera, pleurisy, smallpox, tonsillitis, rheumatism, asthma, malaria, tuberculosis, jaundice,
3. Venereal disease: specific symptoms, signs, the disease by name, treatment.
4. Accidents (date, any disability, sequelae): operation and hospitalization (date, procedure, name
of hospital, physician, complications, bleeding tendency).
Family History: family tendency, presence of hereditary disorders, cancer, tuberculosis, mental disorder and nervous affection, rheumatism, diabetes, hypertension, cerebral vascular accident, hemophilia, syphilis, tumor, epilepsy, allergy, etc., health condition, and cause of death of parents, grandparents, siblings or relatives.
1. Social history: fears, mental status, education, financial condition, number of dependants, family
harmony or friction, hygienic condition at home.
stnd2. Marital history: duration of marriage, 1 or 2 marriage, age and health of spouse and children,
if died, cause and age at time of death, number of children, number of pregnancies, miscarriages,
3. Occupational history: duration of employment, past work, exact nature of work, exposure to
occupational hazards, whether work is satisfactory or not.
4. Habits: alcohol, tobacco, coffee, tea, narcotic, food habits, appetite, regularity of meals, rapidity
of eating, bowel movement, sleep, exercise, interests, etc.