Case Notes - History of presenting illness

Source of history

Witnessed?

Yes

No

Was

Cooperative and reliable

Difficult to contact with

Dependency of care

Independent on ADL

Partially dependent on ADL

Fully dependent on ADL

Who takes care of the patient?

Family

Relative

Friend

The patient was well until

Days

Weeks

Months

Years

Ago

Source of referral (If any)

Hospital name

Department/Clinic

Diagnosed as

Reason of referral

Reason of now visit

Reached limit of tolerance

Reached limit of anxiety

Problems with ADL

Prevention

Administrative reasons

Procedure

Investigation

Management

Raw, undercooked, junk food or drink ingestion

When

Ago

Food Type

Fruit

Vegetable

Milk

Meat

Beef

Pork

Unpasteurised dairy products

Untreated water

Special ingestion

Foreign body

Caustic

Alkali

Acidic

material

History of contact with sick patient

Diagnosis

Symptoms

Similar condition in family, colleagues, co-workers

Yes

No

Psychosocial and emotional stress

Yes

No

Weather changes

Exposed to

Cold

Hot

Humid

Dry

Rainy

Weather

Symptom free period

Yes

No

Awareness, concerns, ideas or expectations about condition

Alert bracelet/necklace

General Condition

Improving

Same

Worsening

History of previous/recurrent infection or illness in the past

Yes

No

General history data