By Yuyuricci

Patient’s Profile
Name:
Age / Gender:
Lives:
Position in family/siblings:
Date of admission:
Date of clerk:
Informant:
Associated features
Chief Complaint:  Fever , High / mild / low grade /
hypothermia
 Cough , non – productive / productive
 Runny nose
HOPI:  Chills
 Rigors
 Fitting
 Nausea & Vomiting , non – projectile /
projectile
 Rashes
 Loose stools
 Headache / Stiff Neck
 Rapid breathing
 Blue face or any part of body
 Lethargy
 Reduce oral intake
 Sick contact
 Water activity recently
 Dengue prone area
 Hx of rodent in house
 Hx of taking outside food

If there’s pain, use SOCRATES.

SYSTEMIC REVIEWS
Cardiovascular – Chest pain / Palpitations / Peripheral oedema

Respiratory – Dyspnoea / Cough / Sputum / Wheeze / Haemoptysis / Chest pain / Runny nose

GI – Lethargy / Loss of Appetite / Nausea / Vomiting / Indigestion / Dysphagia / Weight loss /

abdominal pain / altered bowel habit / loose stool

Urinary – Frequency / Dysuria/ Incontinence / Dark tea-coloured urine / Hematuria/ Oliguria

1
By Yuyuricci

CNS – Blurry of vision / Headache / Fitting / Loss of consciousness /

Confusion

Musculoskeletal – Bone and joint pain / Muscular pain / stiff neck

Dermatology – Rashes / Skin breaks / Ulcers / Skin lesions

PAST MEDICAL HX

Hospitalization

Surgery

DRUG & ALLERGIES

FAMILY HX

DEVELOPMENT HX
Weight:
Height:

Development Milestones
(Refer table)

IMMUNISSATIONS

NUTRIONAL HX

SOCIAL HX

PERINATAL HX
Prenatal hx:
Natal - Mode of delivery/preterm / full term / weight:
Postnatal hx: