History Taking Form
1. Patient's Demographic Data/Profile (Identification)
Name of patient: Ileto, Ryan L. Age: 20
Gender: M Civil status: Single
Address: Floridablanca Pampanga. Date of Birth: September 17, 2002
Contact number: 09193998846
2. Chief complaint: (Reason for seeking medical treatment/ current problem of the
patient) Example: pain, difficulty of breathing)
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3. History of Present Illness: (Chronological onset of symptoms, duration,
frequency, associated signs and symptoms, previous treatment for the problem,
current medications)
Location - Example pain: "Where is the pain now?"
Onset: "How did these feeling started?" or "When did these feelings begin?"
Duration: "How long have you had these feeling?" or "How often do you feel this
way?", "Is it Intermittent or constant?"
Severity: "How bad is the pain now?"-use pain scale from 0-10 Quality: "How would
you describe the pain?"-Ex. sharp, stabbing Associated symptoms: Example nausea
and vomiting.
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4. Past Medical History: : None
a. Past Medical Illnesses, condition, hospitalization, surgery, OB Gyne
(narrative)
Example of Adult illness:
- ( × ) Hypertension
- ( × ) Stroke
- ( × ) Kidney/Renal (specify)
- ( × ) Pulmonary (specify)
- ( × ) Cardiac/Heart (specify)
- ( × ) Diabetes Mellitus
- ( × ) Rheumatoid Arthritis
- ( × ) Bleeding disorder (specify)
- ( ) Cancer (specify)
- ( × ) STD (specify)
- ( × ) Hepatitis ___(A), ___(B), ___(C)
- ( × ) HIV
- Others: None
b. Previous medications: None
c. Allergies:
- Foods (specify) None
- Drug (specify) None
- Chemicals (specify) None
- Environment (specify) None
- Others: None
- No Known allergy: (yes ( ) or no ( × ) )
d. Childhood illnesses: (please check)
- ( × ) Rheumatic fever
- ( × ) Polio
- ( × ) Chicken pox
- ( × ) Measles
- ( × ) Mumps
- Others (specify) None
e. Routine Health Maintenance: (please check)
- ( ×) Pap Smear
- ( × ) Mammography
- ( × ) Routine Breast Self Examination
- ( ×) Rectal Exam
- ( × ) Colonoscopy
- ( × ) Immunization (specify) __________________________________
5. Family History: (please check and specify)
- ( × ) Blood problem
- ( × ) Cancer
- ( × ) Asthma
- ( × ) Hypertension
- ( × ) Diabetes mellitus
- ( × ) Bleeding Disorders
- ( × ) Tuberculosis
- Others: None
6. Social History:
a. Substance abuse: (please check & specify)
- ( × ) Alcohol
- ( × ) Tobacco: pack per day ( × ) number of years smoking ( )
- ( × ) Prohibited Drugs (specify)____________________________________
b. Employment History: (yes or no)
- ( × ) Chemical exposure
c. Sexual History:
- Active (yes ( ) or no( × )).
- Protection used (specify) None
d. Lifestyle (specify)
- Activities (ADL): None
- Hobbies: Games
- Exercise: Jogging
- Diet: None
- Elimination Pattern: None
- Sleep patterns: 8:30 pm
7. Psychological History:
- Mental status: None
