Long case history ---- points,else- chich history

Pt Name                                                                     (add one sided space for D/D based on P/C )

Father Name

Age/Gender
DOA
TOA
MOA
Address

Source of History:

Ki masla ay tay kao to masla ay ?

P/C

HOPI

SYS Review
Ix Now
T/M now
Progress Now

Past Hx/Actual History:

--p/c back then

--hopi back then

--sys review

--past hx

--Ix

--T/M

--Progressions?

CCHAM BVEND SKIFS

For any symptom as :

OD PARA
Onset
Duration

Progression
Aggravating factors
Relieving factors
Associations

CHAM   BVEND   SKIFS

Compliance(who gives,buys,skipped meds?)/Complications/FollowUp(where/how often/any tests?/any meds added or changed ?/

Hospitalizations(how many where,duration?/what were P/C )

ADL(DEATH: Dressing, Eating, Ambulation, Toileting, Hygiene)

Monitoring at home(as in Nephrotic Syndrome, urinary protein.)

Birth Hx

Vaccination

Exercise/Physiotherapy

Nutrition/Feeding Hx(calories: past 24 hours)

Development (may begin by asking about schooling)

Screening(Family)

Knowledge(about disease)

Impact(On Parents, Patient, Sibling,Schooling,Social Life and Activities)

Family History(consanguinity)hwo many siblings?siblings deaths/?
Social history (own home?rooms?families in home?members?earning? fridge-bike?/water for drinking?/sanitation/ eating red meat?