This is a pdf document for internship students who will be using this form to help with the history taking and physical examination.

1. Internal Medicine and Surgery
Dr. Ayub Abdulkadir Abdi

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HISTORY TAKING AND PHYSICAL EXAMINATION ‘FORM’ FOR MEDICAL
STUDENT ‘Internal Medicine & Surgery’ - 2021
Designed by: DR. Ayub Abdulkadir Abdi
Student Name: ____________________________________ Level: □ Internship □ Fellowship □ Other
PERSONAL DETAIL:
Patient name: ______________________________________________________ Age: _________ Sex: ______
Date of birth: _____________ Place of birth: __________________ Home address: _____________________
City: _______________ Date of admission: ______________ Referring doctor: □ Yes □ No
Marital state: □ Single □ Married □ widowed □ Divorced Mobile/tell: _______________________
Occupation: □ Job □ Jobless Patients relative name: _________________________________________
Relative address __________________ Relative tell/mob: ___________________
VITAL SIGN:
Blood Pressure: _____________________ Weight: ___________ BMI: __________ Temperature: _________
Respiratory Rate: __________________ Pulse Oximeter: ____________
CHIEF COMPLAINT: (Duration)
1. ____________________________ ( )
2. ____________________________ ( )
3. ____________________________ ( )
4. ____________________________ ( )
5. ____________________________ ( )
HISTORY OF PRESENT ILLNESS: SOCRATES
1.
2.
S
O
C
R
A
T
E
S

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3.
4.
PAST MEDICAL HISTORY:
 Childhood disease
1.
2.
3.
4.
 Chronic medical disease:
Disease & disorder: Hospital Diagnosis: Treatment:
1. □ Hypertension. ___________________
2. □ Diabetic. ___________________
3. □ Tuberculosis. ___________________
4. □ Heart disease (like MI, HF,). ___________________
5. □ Neuropathy. ___________________
6. □ Chronic back pain. ___________________
7. □ Others:
S
O
C
R
A
T
E
S

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 Immunization:
Name of vaccine: Hospital name Date:
1. □ BCG ___________________ / /
2. □ MMR. ___________________ / /
3. □ DTP. ___________________ / /
4. □ Hepatitis □ A □ B □ C ___________________ / /
5. □ Corona virus: □ 1 dose □ 2 dose ___________________ / /
6. □ Others:
 Hospitalization:
Date: Hospital name Reason Management:
1. _____________ ___________________ ___________________ ___________________
2. _____________ ___________________ ___________________ ___________________
3. _____________ ___________________ ___________________ ___________________
4. _____________ ___________________ ___________________ ___________________
5. _____________ ___________________ ___________________ ___________________
 Surgical Procedure:
Date: Hospital name Location of procedure Reason of procedure:
1. _____________ ___________________ ___________________ ___________________
2. _____________ ___________________ ___________________ ___________________
3. _____________ ___________________ ___________________ ___________________
4. _____________ ___________________ ___________________ ___________________
5. _____________ ___________________ ___________________ ___________________
 Medical Imaging:
Hospital name and date Location of imaging Reason of imaging:
□ ECG ___________________ ___________________ _________________________
□ X- ray ___________________ ___________________ _________________________
□ Ultrasound. ___________________ ___________________ _________________________
□ MRI. ___________________ ___________________ ________________________
□ CT scan. ___________________ ___________________ ________________________
□ Endoscopy. ___________________ ___________________ _________________________
□ EEG. ___________________ ___________________ _________________________
□ EMG. ___________________ ___________________ _________________________
□ Others:
 Screening test: Hospital name and Date:
1. PAP smear. _______________________________________
2. Colposcopy. _______________________________________
3. Mammogram. _______________________________________
4. Others
 Injury and trauma: Intervention:
1.____________________________________ □ YES □ NO
2.____________________________________ □ YES □ NO
3.____________________________________ □ YES □ NO
4.____________________________________ □ YES □ NO

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 Obstetric History:
Disease or disorder Hospital admission & date: Management:
1. _______________________________ ___________________ ___________________________
2. _______________________________ ___________________ ___________________________
3. _______________________________ ___________________ ___________________________
4. _______________________________ ___________________ ___________________________
5. _______________________________ ___________________ ___________________________
Surgical procedures Hospital admission & date: Management:
1. _______________________________ ___________________ ___________________________
2. _______________________________ ___________________ ___________________________
3. _______________________________ ___________________ ___________________________
4. _______________________________ ___________________ ___________________________
5. _______________________________ ___________________ ___________________________
 Gynecologic History:
Disease or disorder Hospital admission & date: Management:
1. _______________________________ ___________________ ___________________________
2. _______________________________ ___________________ ___________________________
3. _______________________________ ___________________ ___________________________
4. _______________________________ ___________________ ___________________________
5. _______________________________ ___________________ ___________________________
Surgical procedures Hospital admission & date: Management:
1. _______________________________ ___________________ ___________________________
2. _______________________________ ___________________ ___________________________
3. _______________________________ ___________________ ___________________________
4. _______________________________ ___________________ ___________________________
5. _______________________________ ___________________ ___________________________
FAMILY HISTORY:
Your parents are they alive? □ YES □ NO.
Are you dependent with your family □ YES □ NO.
Your wife or husband are they: □ Cousins. □ Non – cousins. □ Tribe □ Non – Tribe.
Your wife or husband age: □ 15 – 25y □ 25 – 45y □ 45 – 65y.
Number of children □ NO □ YES = Boys ( ) Girls ( )
Do you have brother and sister. □ NO □ YES = Brother ( ) Sisters ( )
o Recent family illness: □ YES □ NO
Cause of illness: ________________________ Who ________________ Age _____________.
Cause of illness: ________________________ Who ________________ Age _____________.
Cause of illness: ________________________ Who ________________ Age _____________.
o Chronic family disease: □ YES □ NO
Cause of disease: _______________________ Who ________________ Age _____________.
Cause of disease: _______________________ Who ________________ Age _____________.
Cause of disease: _______________________ Who ________________ Age _____________.
Cause of disease: _______________________ Who ________________ Age _____________.
Cause of disease: _______________________ Who ________________ Age _____________.

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o Recent family death: □ YES □ NO
Cause of death: _________________________ Who ________________ Age _____________.
Cause of death: _________________________ Who ________________ Age _____________.
Cause of death: _________________________ Who ________________ Age _____________.
Cause of death: _________________________ Who ________________ Age _____________.
Cause of death: _________________________ Who ________________ Age _____________.
o Genetic family disease: □ YES □ NO
Type of disease: ________________________ Who ________________ Age _____________.
Type of disease: ________________________ Who ________________ Age _____________.
MEDICATION AND ALLERGY HISTORY:
 Allergy:
 Medications:
 Present:
Drug name
Prescribed or Not
Hospital
Quantity
Dosage
Reason for use
Adverse or side
effect.
 Past:
Drug name
Prescribed or Not
Hospital
Quantity
Dosage
Reason for use
Adverse or side
effect.
Causes of allergy and its duration:
□ Food □ Chemicals □ Inhaler □ Cloths □ Jewelry
1. _________________________ (Duration) ______
2. _________________________ (Duration) ______
3. _________________________ (Duration) ______
4. _________________________ (Duration) ______
Sign and symptoms of allergy:
□ Sneezing □ Wheezing □ Dyspnea
□ Cough □ Sore of throat □ Nasal
Congestion □ Skin rash □ Itching □
Burning □ Vomiting □ Nausea □
Diarrhea □ Dizziness □ Swelling
□ Fever □ Red eye.
Family history of allergy:





Drugs used for allergy:
Name: Hospital
_______________ ____________
_______________ ____________
_______________ ____________
_______________ ____________

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SOCIAL HISTORY:
 Level of education:
□ Non reading and writing □ Primary school □ Intermediate □ Secondary □ University
 Living arrangement:
□ Apartment □ Hotel □ Privacy □ Crowded house □ Public house □ Government house
 Water and electrical supply:
□ Pipe water □ Well water □ River □ No electric supply □ Solar □ 24 hour electric
 Family Income:
□ Mild □ Moderate □ 5 $/day □ 15 $/day □ 100 $/moth □ > 200 $/month. □ Privacy
 Occupation:
 Present:
Type of job
Income
Medical related illness.
Type of Exposure
Does people affect your job.
Would you like to change you job.
Safety work place
Duration of employment
 Past:
Type of job
Income
Medical related illness.
Type of Exposure
Does people affect your job.
Would you like to change you job.
Safety work place
Duration of employment
 Hobbies and leisure activities:
 What is your favorite hobbies? ___________________________________
 How long does take your favorite hobbies? ___________________________________
 What do you like to do your free time? ___________________________________
 Have you ever travel to country? ___________________________________
 What type of travel agent you follow? ___________________________________
 Do you have a vaccination? ___________________________________
 What type of food do eat on your holiday? ___________________________________
 Where does your food come from? ___________________________________
 Have you suffer a disease during holiday? ___________________________________
 How long do you read a book? ___________________________________
 Who accompanies you during the holiday? ___________________________________
 Sexual history:
o How do you know your partner ready for sex?
o How much number of partner do you have a sex?
o What are the frequency of sexual intercourse you do?
o What are the type of sexual practice?
o Can he/she says no?

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o How does one deal with anger, rejection, & loneliness?
o Can she/he openly talk to partner about their feeling?
o Have you had any infection?
Sing and symptoms.
Medication.
o How is your partner?
o What kind of protection did you use during sex intercourse?
o What was the last sexual intercourse?
o Do you have a chronic disease like HTN DM?
o Have you ever suffer sexual dysfunction?
 Bad Habit:
Smoking / Hashish Tobacco / Khat Alcohol Drug abuse
Type
Current use
Past use
Reason for using
Amount
Duration
Daily or Intermittent
Hospitalization
Medical
complication
Have you ever tried
to stop
Felt angry from
people criticizing
Do you feel guilt
Use of morning

9. SYSTEMIC REVIEW:
 General:
□ Recent weight loss.
□ Recent weight gain.
□ Fatigue.
□ Weakness.
□ Fever.
□ Night sweats.
 Skin:
□ Change color
□ Rash
□ Itching.
□ Hair loss.
□ Change hair color.
□ Change nail.
 Head:
□ Headache.
□ Head injury.
□ Hair change.
□ Loss of hair.
 Eye:
□ Redness.
□ Itching.
□ Discharge.
□ Pain.
□ Photophobia.
□ Change in vision.
□ Double vision.
□ Recent weight gain.
□ Fatigue.
□ Glasses.
□ Dry eye.
□ Excessive tearing.
□ History of glaucoma.
 Ear:
□ Change in hearing.
□ Ear pain.
□ Ear discharge.
□ Ringing.
□ Dizziness.
□ Vertigo.
□ Ear infection.
 Nose/Sinuses:
□ Sinusitis.
□ Nose bleeding.
□ Nasal stuffiness.
□ Frequent cold.
□ Loss of smelling.
□ Nasal pain.
□ Nasal discharge.
□ Trauma.
 Mouth/Throat:
□ Sore throat.
□ Hoarseness.
□ Difficult in swallowing.
□ Pain in jaw.
□ Gum bleeding.
□ Sore tongue.
□ Bad breathing.
 Neck:
□ Lump.
□ Pain.
□ Itching.
□ Neck skin change.
□ Stiffness.
□ Neck compression.
 Breast:
□ Pain.
□ Discharge.
□ Itching.
□ Mass.
 Lung/Heart:
□ Chest pain.
□ Shortness of breathing.
□ Cough.

10. □ Sputum.
□ Wheezing.
□ Bleeding.
□ Coughing of blood.
□ Fever.
□ Respiratory infection.
□ Skipping heart beat.
□ Fainting.
□ Swollen hand and feet.
□ Syncope.
□ High blood pressure.
□ Intermittent claudication.
□ Orthopnea.
 Gastrointestinal:
□ Change in appetite.
□ Loss of weight.
□ Difficult of swallowing.
□ Nausea.
□ Vomiting.
□ Heartburn.
□ Excessive salivation.
□ Vomiting of blood.
□ Diarrhea.
□ Constipation.
□ Change in bowel habit.
□ Abdominal pain.
□ Excessive belching.
□ Excessive flatus.
□ Jaundice.
□ Surgical scar.
□ Trauma.
□ Food intolerance.
□ Food allergy.
□ Rectal bleeding.
□ Hemorrhoids.
 Urinary:
□ Frequency.
□ Urgency.
□ Hesitancy.
□ Oliguria.
□ Polyuria.
□ Anuria.
□ Pain during urination.
□ Urine Color.
□ Incontinence.
□ Dribbling.
□ UTI.
□ Flank pain.
□ Suprabupic pain.
□ Blood urine.
 Reproduction:
□ Decreased desire.
□ Pain during intercourse.
□ Genital discharge.
□ Genital ulcer.
□ Genital lump.
□ Genital bleeding.
□ Erectile dysfunction.
□ Decreased sex organ.
□ Genital itching.
□ Irregular menses.
□ Abnormal odor.
□ Trauma.
□ Surgical procedure.
 Skin:
□ Rash.
□ Color.
□ Itchy.
□ Skin infection.
□ Nodules.
□ Hear loss.
□ Color changes in hands and feet.
□ Skin dry.
□ Skin moist.
□ Excessive sweating.
□ Bruising.
 Musculoskeletal:
□ Leg pain.
□ Joint pain.
□ Joint swelling.

11. □ Numbness.
□ Muscle weakness.
□ Muscle stiffness.
□ Bone fracture.
□ Decreased joint motion.
□ Sprain.
□ Back pain.
□ Bed sore.
□ Trauma.
 Neurologic:
□ Headache.
□ Dizziness.
□ Fainting.
□ Loss of consciousness.
□ Memory loss.
□ Tingling or numbness.
□ Seizure.
□ Paralyses.
□ Tremor.
□ Involuntary movement.
□ Weakness.
□ Incoordination movement.
□ Loss of sensation.
 Endocrine:
□ Abnormal growth.
□ Increased appetite.
□ Increased thirst.
□ Increased urine output.
□ Excessive sweating.
□ Heat intolerance.
□ Cold intolerance.
□ Increased pigmentation.
 Vascular:
□ Leg cramp.
□ Varicose vein.
□ Thrombophlebitis.
□ Ulcer.
□ Vein clot.
 Hematological:
□ Anemia.
□ Bleeding.
□ Bruising.
□ Lymphadenopathy.
□ Transfusion allergy.
 Psychiatric:
□ Depression.
□ Excessive worries.
□ Difficult falling asleep.
□ Difficult staying asleep.
□ Poor appetite.
□ Difficult in sexual arousal.
□ Frequent crying.
□ Sensitive.
□ Stress.
□ Attempt to suicide.
□ Irritability.
□ Poor concentration.
□ Racing thought.
□ Hallucination.
□ Rapid speech.
□ Guilty thought.
□ Risky behavior.
□ Change of mood.
□ Change of attitude.
 Others:
□
□
□
□
□
□
□
□
□
□
□
□
□
□

12. PHYSICAL EXAMINATION
General: Comment:
1. General appearance. ______________________________
2. Level of consciousness. ______________________________
3. Number of people at the room. ______________________________
4. Room temperature. ______________________________
5. Any device connected to the patient. ______________________________
6. ______________________________
7. ______________________________
8. ______________________________
Systemic:
System name: ______________________________
System name: ______________________________
Inspection:
1.
2.
3.
4.
5.
6.
Palpation:
1.
2.
3.
4.
5.
6.
Percussion:
1.
2.
3.
4.
5.
6.
Auscultation:
1.
2.
3.
4.
5.
6.
Inspection:
1.
2.
3.
4.
5.
6.
Palpation:
1.
2.
3.
4.
5.
6.

13. System name: ______________________________
System name: ______________________________
Percussion:
1.
2.
3.
4.
5.
6.
Auscultation:
1.
2.
3.
4.
5.
6.
Inspection:
1.
2.
3.
4.
5.
6.
Palpation:
1.
2.
3.
4.
5.
6.
Percussion:
1.
2.
3.
4.
5.
6.
Auscultation:
1.
2.
3.
4.
5.
6.
Inspection:
1.
2.
3.
4.
5.
6.
Palpation:
1.
2.
3.
4.
5.
6.
Percussion:
1.
2.
3.
4.
5.
6.
Auscultation:
1.
2.
3.
4.
5.
6.

14. Examination of □ Mass □ Ulcer
1. Site: ___________________________________
2. Size: ___________________________________
3. Shape: ___________________________________
4. Surface: ___________________________________
5. Skin: ___________________________________
6. Tenderness: ___________________________________
7. Temperature: ___________________________________
8. Transillumination: ___________________________________
9. Consistence: ___________________________________
10.Appearance of patient: ___________________________________
11.Mobility: ___________________________________
12.Pulsation: ___________________________________
13.Fluctuation: ___________________________________
14.Irreducibility: ___________________________________
15.Regional lymph node: ___________________________________
16.Edge: ___________________________________
Examination of □ Mass □ Ulcer
1. Site: ___________________________________
2. Size: ___________________________________
3. Shape: ___________________________________
4. Surface: ___________________________________
5. Skin: ___________________________________
6. Tenderness: ___________________________________
7. Temperature: ___________________________________
8. Transillumination: ___________________________________
9. Consistence: ___________________________________
10.Appearance of patient: ___________________________________
11.Mobility: ___________________________________
12.Pulsation: ___________________________________
13.Fluctuation: ___________________________________
14.Irreducibility: ___________________________________
15.Regional lymph node: ___________________________________
16.Edge: ___________________________________