Patients identification

Name :

Registration no :

Date of birth:

Bed no :

Age :

Ward no :

Sex :

Date of admission :

Religion :

Date of examination :

Race :

Informant :

Address :

Others :

Chief complaints
(Problems with duration)

1.

2.

3.

History of present illness

Systemic enquiries

Respi Cough Haemoptysis Sputum(colour amount and smell) wheezing Sob Dyspnea

CVS Palpitation Shortness of breath Chest pain Leg swelling Poor feeding Cyanosis
Urine tract - Dysuria Haematuria Nocturia Incontinence Urine colour
GIT - Loss of appetite Nausea and vomiting Constipation Diarrhea Abdominal pain
CNS - Vision Hearing Numbness Dizziness Seizure Faints Memory & Concentration
MSK Lethargy Muscle pain Joint pain Stiffness Immobility
Skin Itchiness Swelling Rashes History of skin allergy Bleeding
Endocrine Cold or heat intolerance Change in sweating
ENT Ear or nose discharge

History of past illness

Medical:

Surgical:

Birth history

Antenatal:

Regular attended antenatal clinic (ANC)

Inj. aTT given
Any fever with rash during pregnancy
(particularly in the first trimester)
Serology tests; Hep B, Hep C, VDRL &
HIV
Medications for current pregnancy
Chronic illness or Any trauma

Natal:

Gestational age

Mode of delivery with presentation

Prolonged labour and oxytocin used
PROMif yes offensive liquor or meconium
staining liquor
Maternal fever with lower abdominal
tenderness (chorioamnionitis)
C/S done- indications
Type of anaesthesia

Postnatal:

Cried well/vigorously immediately after birth

Birth weight (gm or kg)
Neonatal jaundice
Sepsis & meningitis
Pneumonia
Hypoglycaemia
Convulsions

Neonatal:

Any significant illness exp: pneumonia,

meningitis or asthma
First urine output and meconium (24 hrs)
When start breastfeed ??
How long ??

Feeding and dietary history

Breastfeeding amount & frequency of milk offered :

Formula feeding :
Prelacteal feeding:

Complementary feeding (Start time & food offered) :

Current dietary intake:

Immunization history
Malaysian national EPI schedule -

Developmental history

Gross motor:

Vision & fine motor:

Hearing, speech & language:

Social, emotional & behavioural:

Treatment & allergy history

Drug reaction or allergy :

Food allergy :

Family history

Consanguinity of marriage
Siblings: number, age & sex, their health

Familial illness

Maternal illness
History of miscarriage, abortion, IUD, still birth
and neonatal death

Socio-economic history

Adequate basic facilities (adequate water supply, proper sanitation, good ventilation)
Good source of light.
House is located in a housing area and not near highway or factory
Pets and carpet

Mother works (salary)

Father works (salary)
Smoke???
Alcohol???
OC pills ???

Personal history

Summary and DIAGNOSIS