ishu
Forum Newbie
Topics: 9
Posts: 30
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ple make comments or suggestion about the following format of history taking
thankyou
1) Knock the door 3 times
2) walk in with smile and confidence and say HELLO Mr. XXXX. I am Dr. ZZ
I am here to see u today as u r physician. Shake hands
3) look around and say “ is every thing in this room ok with u?”
answer yes… ok let me more comfortable by putting this drape on you..
4) ok Mr. XXXX Tell me how may I help you?
Ans C.C
Oh sorry to hear about that, I hope you don’t mind if I make few notes as we go on discussing more on this problem..
Onset duration
Associated symptoms progression
Relieving factors aggravating factors
Will add more questions according to the case
5)Thank you mr. XXXX now I need to ask you few questions about your health in past , is that ok with you? Thank you, can I proceed?
Ok Mr. XXXX
Have you ever had similar complaints before?
Have you ever had any other complaints?
Have you ever been diagnosed with high BP/B. sugar / cholesterol ?
6)Are you allergic to any medication?
Were ever diagnosed with asthma?
7)Are you using any medication?
8)Have you ever been hospitalized over night before?
9)Do u have any problems with your urination?
10)Do u have any problems with your bowel movement?
11)Do u have any problems with your sleep?
Thank you Mr. XXXX for answering all my questions , now I need to ask you few questions about your family health in general, is that ok with you?
Thank you , can I proceed?
12)Are your parents alive?
No.. I am so sorry to hear that. How did he/she die?
Yes.. how r they doing? Does any one in your family ever been diagnosed with high BP/Blood sugar/ cholesterol?
13)OBGYN if pt is female..
When was your LMP, how many pads do you change, are there any associated complaints?
Ok mr.XXXX now I need to ask you few questions about your sexual behavior, I can assure you that what ever we are going to discuss here will be kept confidensial. Is that ok with you. Thank you , can I proceed?
14)Are you sexually active?
How many partners do you have?
Are you using condoms regularly?
15)Do you use tobacco in any form?
How many cigarrets do u smoke perday?
16)Do you drink alcohol?
How much alcohol do u consume per day?
Thank you mr.XXXX for answering all my questions .
At this point is there any thing else you want to tell me?
Ok mr.XXXX now I need to do a brief physical examination on you. Is that ok with you , can I proceed? Ok let me wash my hands..
Edited by ishu on 02/16/08 - 04:24 PM
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| ishu
Forum Newbie
Topics: 9
Posts: 30
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hey guys iam inviting u r comments on this post, ple do
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| treblechar
Forum Junior
Topics: 4
Posts: 92
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ideally yes. but be prepared for out of the box case scenarios.
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