Clinical round tool

History taking

A practical general-history checklist for students: collect the patient story, avoid missing core criteria, then copy a clean presentation summary.

0 / 0 criteria checked

Opening

Start here

Introduce yourself and confirm patient identity. Ask permission to take the history and to write notes. Confirm the source of history and reliability when relevant. Use open questions first, then focused questions.

Biodata

Patient identity

Name or initials Sex Occupation Residence Marital status History source

Age: choose date of birth or type age manually

Date of birth Manual age

Name Age Sex Occupation Residence

Complaint

Main problem

Chief complaint Duration Mode of onset

Chief complaint in patient's words Duration Chronology and progression Associated symptoms Important negatives

Symptom analysis

Use when the complaint is pain or a focused symptom

Site Onset Character Radiation Associated symptoms Timing / course Exacerbating factors Relieving factors Severity

Past history

Medical, surgical, and admission history

Hypertension Diabetes mellitus Cardiac disease Renal disease Hepatic disease Asthma / COPD

Chronic diseases Previous admissions Surgical history Blood transfusion / accidents when relevant

Drug and allergy history

Current and previous treatment

Current medications Dose and compliance Allergies and reaction

Vaccination and family

Prevention and relatives

Vaccination history Similar condition in family Hereditary or common family diseases

Social and habits

Daily life and exposures

Smoking Alcohol Substance use Occupational exposure

Smoking Alcohol Substance use Occupation and environmental exposure

Review of systems

Screen related systems without turning it into a full lecture

General: fever, weight loss, appetite, fatigue Cardiovascular: chest pain, dyspnea, palpitations, edema Respiratory: cough, sputum, wheeze, hemoptysis Gastrointestinal: vomiting, dysphagia, bowel habit, bleeding Urinary: dysuria, frequency, hematuria, urine output Neurologic: headache, weakness, fits, sensory symptoms

Presentation draft

Case summary

Fill the form to generate a presentation summary.

For learning support only. Students should follow local department instructions and patient privacy rules.