The following is a consultation template compiled by the editor. After reviewing it, if there are any inaccuracies or additional information needed, please raise them in the comments section for modification, to avoid misleading others and to help interns and students avoid detours.
Name: Gender:
Age: Marital Status:
Ethnicity: Occupation:
Place of Origin: Current Address:
Admission Date: Record Date:
History Narrator: Patient himself/herself Reliability: Reliable
1. Main Complaint: Summarize in one or two sentences, not exceeding twenty words. The main complaint describes the symptoms, not the diagnosis made by the doctor. For example, “sore throat for 2 days” should not be written as “pharyngitis for two days”.
2. Present Illness History (After inquiring to a certain extent, there should be preliminary diagnoses based on experience, and similar diagnoses should be ruled out. When it is impossible to diagnose the disease accurately through inquiry, auxiliary examinations should be conducted. Of course, this is difficult for those just entering the medical field.):
Past Conditions and Duration of Illness:
Main Symptoms Characteristics:: If there is fever, ask what the temperature is; if there is pain, ask about the location, onset time, duration, and nature of the pain, whether it is dull or sharp; Etiology and Triggers: If there are no triggers, write “no obvious triggers”.
Progression and Evolution of the Condition:
Treatment History:: Where treatment has been conducted (generally can be asked), what medications were used, dosage, and duration (if medication names and dosages cannot be obtained, write “medication name unknown, dosage unknown”), and the effectiveness of the treatment.
General Condition During the Course of Illness:: Mental state, sleep condition, physical strength, changes in appetite and food intake (changes should be inquired about, e.g., food intake is half of what it was before the illness), bowel and bladder conditions, weight changes (if no change, write “no significant change”; if there is a change, the extent of the change should be noted).
3. Past Medical History: Past illnesses (any previous diseases should be noted, then inquire about treatments received, medications used, dosages, duration, and treatment effectiveness), history of trauma or surgery, history of drug allergies.
4. System Review: During the inquiry, one can summarize and then confirm with the patient, but this is generally not done.
It is generally required to write down which diseases correspond to which systems when writing medical records.
5. Personal History:
Social Experience: Epidemic Source Area:
Occupation and Working Conditions: Mainly whether there is exposure to industrial toxins.
Habits and Preferences: Smoking (how long has the person been smoking; if they quit, how long has it been since quitting), drinking (how much alcohol consumed).
6. Marital History: When inquiring, attention should be paid to age; for older individuals, inquire whether they have children, rather than whether they are married.
7. Menstrual and Reproductive History: For women over 50, first inquire whether they still have menstruation; if not, ask when menopause occurred; if they do, proceed with the inquiry step by step.
8. Family History: Inquire about any hereditary diseases in the family, and any similar disease histories.