History Taking Format
Hello, Mr/Mrs/Miss. . I am Dr. , one of the doctors in this department. I am here to ask you some questions about your condition. Is that OK? I assure you whatever we talk will be strictly confidential.
Present Illness
What brought you to the hospital today? (Could you tell me what happened?)
Can you describe more about your symptom?
Has this happened before?
O (nset) = When did it start? What were you doing when it started?
D (uration) = How long did it last?
I (ntensity) = Was it severe or mild?
P (rogression) = Is it getting worse, better or same since onset?
AR (aggrevating and relieving factor)
= Have you noticed anything to make it worse or better?
Associated Symptom = Did you notice any other symptoms?
(Were there any other symptoms before or after this episode?)
Anything else = Do you have anything else you would like to tell me about?
SOCRATES
(Site, Onset, Character, Radiation, Associated symptoms, Timing, Exacerbating/relieving factor, Scale)
Consider DDx and ask relevent questions
Did you notice any change in – Sleep Appetite, Diet, BW, Bowel habit, Waterworks
Past = Have you had any medical problem or surgery before?
HT, DM, Heart, Blood clot, Asthma
Personal = Smoking, Alcohol
Sex- Are you sexually active, Are you in a stable relationship?
I’m sorry to ask you this but do you have any other partners?
More than one partner?
M = Are you on any medication including over-the-counter medications?
A = Are you allergic to any medications?
F = Is there anybody in your family with the same problem?
T = Did you travel abroad recently?
O = What do you do for a living?
S = Do you live alone or with others? Was anyone with you when it happened?
A = Do you have anything else you want to talk about?
(P3 MAFTOSA). In present illness we have to ask ODIPARAA or SOCRATES (is suitable when there is a pian symptom)
However, I would like to take more detailed history, do relevant clinical examination and discuss with my seniors.
Thank you very much for answering my questions. You have been very cooperative.
OBGY
P = Period
When was your LMP?
How many days do they last?
Are they regular?
How many weeks between each period?
Do you get pain? Any bleeding between your period? Or after intercourse?
P = Pregnancy
Have you ever been pregnant? How many children do you have?
Any miscarriage? Duration of pregnancy?
Mode of delivery? Any complication before, during or after pregnancy?
P = Pills (Are you taking pill? Are you on any contraception?)
P = Pap smear (When did you take Pap smear?)
(P7 MAFTOSA)
PAEDIATRICS (BIRD MAFA)
Birth = Was everything fine at the time of birth and just after that?
Immunisation = Is your child up-to-date with jabs?
Red book = Are you happy with the red book of your child?
Development = How do you see development of your child?
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