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 Appetite
 Diet
 Weight
 Nausea
 Dysphagia.
 Regurgitation
 Flatulence
 Heartburn
 Vomiting
 Hematemesis
 Indigestion pain
 Abdominal pain.
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 Jaundice
 Abdominal distension
 Bowel habit.
 Nature of stool.
 Rectal bleeding.
 Mucus.
 Slime.
 Prolapse.
 incontinence.
 Tenesmus
(b) Respiratory system
 Cough.
 Sputum.
 Hemoptysis.
 Dyspnea.
 Hoarseness.
 Wheezing.
 Chest pain.
 Exercise tolerance
(c) Cardiovascular system
 Dyspnea.
 Paroxysmal nocturnal dyspnea.
 Orthopnea.
 Chest pain.
 Palpitations.
 Ankle swelling.
 Dizziness.
 Limb pain.
 Walking distance.
 Color changes in hands and feet

(d) Urogenital system

 Loin pain.
 Frequency of micturition including nocturnal frequency.
 Poor stream.
 Dribbling.
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 Hesitancy.
 Dysuria.
 Urgency.
 Precipitancy.
 Painful micturition.
 Polyuria.
 Thirst.
 Haematuria.
 Incontinence
In males:
 Problems with sexual intercourse and impotence

In females:
 Date of menarche or menopause.
 Frequency.
 Quantity and duration of menstruation.
 Vaginal discharge.
 Dysmenorrhea.
 Dyspareunia.
 Previous pregnancies and their complications.

 Prolapse.
 Urinary incontinence.
 Breast pain.
 Nipple discharge.
 Lumps.
 Skin changes
(e) Nervous system
 Changes of behaviour or psyche.
 Depression.
 Memory loss.
 Delusions.
 Anxiety.
 Tremor.
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 Syncopal attacks.
 Loss of consciousness.
 Fits.
 Muscle weakness.
 Paralysis.
 Sensory disturbances.
 Paraesthesias.
 Dizziness.
 Changes of
• smell
• vision
• hearing
 Tinnitus.
 Headaches
(f) Musculoskeletal system
 Aches or pains in muscles, bones or joints.

 Swelling joints.
 Limitation of joint movements.
 Locking.
 Weakness.
 Disturbances of gait
Previous history (PH)
 Previous illnesses.
 Operations or accidents.

 Diabetes.
 Rheumatic fever.
 Diphtheria.
 Bleeding tendencies.
 Asthma.
 Hay fever.
 Allergies.
 Tuberculosis.
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 Sexually transmitted diseases.

 Tropical diseases
Drug history:
 Insulin.
 Steroids.
 Antidepressants
 contraceptive pill.
 Drug abuse
 Other

Immunizations:
 BCG.  Typhoid.
 Diphtheria.  Whooping cough.
 Tetanus.  Measles

Family history (FH)

 Causes of death of close relatives

 Familial illnesses in siblings and offspring

Social history (SH)

 Marital status.
 Sexual habits.
 Living accommodation.
 Occupation.
 Exposure to industrial hazards.
 Travel abroad.
 Leisure activities
Habits
 Smoking
 Drinking
 Other
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Pain History:
Site
Time of onset
Mode of onset
Severity
Nature/character
Aching burning stabbing constricting throbbing distending colicky
Progression

The end of the pain

Duration

Relieving and exacerbating factors

Radiation

Referral

Cause