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What questions should you ask regarding past medical history?
______________________________ Do you have any past medical diagnosis and treatment? ______________________________ What was the diagnosis and treatment? ______________________________ Who, where, and when did he or she diagnose and treat you? ______________________________ Do you think he/she diagnosed and treated you correctly? ______________________________ Did the diagnosis and treatment improve your medical condition? ______________________________ Did you have similar problems in the past? ______________________________ Was there any incident in the past 10 years that physically or psychologically hurt you? ______________________________ Do you have any relatives, friends, or acquaintances with a similar problem? ______________________________ Do you know anyone with a similar problem? ______________________________ Have you seen anyone with a similar problem? ______________________________ Do you have any existing medical condition? ______________________________ Did you have any previous medical condition that does not exist now? ______________________________ Do you take any medications now? ______________________________ Did you take any medications in the past that you are not taking now? ______________________________ Do you think any health care details need to be added? ______________________________ Did you have any of these in the past year? Fall. Road traffic crash. Assault. Any type of trauma. Any type of harm. ______________________________ Is there any incident or issue in past, present, or future that is causing distress to you? ______________________________ Did you experience any one of these that has troubled you since the day you were born? Assault. Accidents. Building collapse. Child abuse or captivity. Childbirth. Death of a loved one. Domestic violence. Fire. Genocide. Natural disaster (hurricanes, earthquakes, tsunamis). Neglect of a child leading to a serious harms. Nutritional deficiency. Road traffic crash. Rape. Shooting. Torture. War. ______________________________ If yes, what are the details? ______________________________ If any other traumatic, stressful, harmful, or horrifying event, give more details. ______________________________ What specific medicine have you taken in the past month? ______________________________ What is the name and dose you are taking? ______________________________ Who prescribed the medicine? ______________________________ When did he/she prescribe the medicine? ______________________________ Did the patient receive any medication in the past 24 hours? ______________________________ What was the route of administration? ______________________________ Did anyone harm you in the past 10 years? ______________________________ If you have been harmed, you should seek remedies and adjudication. ______________________________ How should you initiate remedies and adjudication for harms? ______________________________ This comes under legal education. About how long has it been since you last visited a doctor for a routine checkup? ______________________________ Within the past 1 month, 6 months, 1 year, 2 years, 5 years, Never Unsure Did you try to hurt yourself or others in the past year? ______________________________ Over the past year, how many times have you visited the emergency room of a hospital? ______________________________ 0 1 2 3 4 5 6 Unsure Did you ask to go yourself or did someone else recommend that you go to the emergency room or for hospitalization? ______________________________ Was your going to the emergency room or for hospitalization justified? ______________________________ Yes No Unsure Over the past year, how many times have you been admitted to the hospital? ______________________________ During the past month, other than as part of a normal day, did you participate in any physical activities or exercise, such as running, biking, gardening, or walking? ______________________________ Yes No Unsure In general, compared to other people of the same age, would you say that your health is excellent, very good, good, fair, poor, or are you unsure? If anything is troubling you, what are the details? ______________________________ Community In the past year, have you ever worked together with someone or some group to make the community a better place to live? ______________________________ Yes No Unsure How much of the time during the last month have you been a happy person? ______________________________ All of the time Most of the time A good bit of the time Some of the time A little of the time None of the time Don't know Is there past medical history of any medical condition, including high blood pressure, diabetes, pulmonary problems, or cardiovascular disease? ______________________________ What medications has the patient been, or is supposed to be, taking (including over-the-counter medications)? ______________________________ Does the patient have any known medical allergies? ______________________________ Did you fall or have any imbalance while walking in the past year? ______________________________ How many times were there falls or imbalance while walking in the past year? ______________________________ What are the details of the fall or imbalance while walking in the past year? ______________________________ If you fell or had any imbalance while walking in the past year, do you think it was because of vision weakness, dim light in the area, improper environment, or any other cause? ______________________________ Harassment Did you face any harassment, embarrassment, provocation, abuse, deprivation of rights, or distress from any source in the past year? ______________________________ If yes, what are the details? ______________________________ What were the day, date, time, location, issues, and circumstances of the incident? ______________________________ Medication What medication have you been taking every day in the past year? ______________________________ Food Are you eating nutritious food every day? ______________________________ Who cooks at home every day? ______________________________ Who brings groceries, other food, and supplies to your home every day? ______________________________ Who brings food to the table or dastarkhan? ______________________________ Is he or she able to do this properly? ______________________________ Did any medical doctor advise any special diet at any time in the past year? ______________________________ If you have any health or any other concerns now, what are the details? ______________________________ If you would like to have any change or difference in your life now, what would it be? ______________________________ Blood biochemical tests When were your last blood biochemical tests done? ______________________________ What are the details of your last blood biochemical tests? ______________________________ If you have not had blood biochemical tests in the past year, you need to have them as part of a routine health checkup. Forward details of blood biochemical tests via e-mail. What do you have to do? What do Mummy (Aisha) and Daddy (M. S. Qureshi) have to do to maintain good health? Here are various health care guidelines. Maintain a healthy routine every day. If you have any issue or concerns, update your health record immediately. If there is any type of meeting, get answers to relevant questions before the meeting. Will you be comfortable in the meeting environment? Do not attend any meeting or condolence meeting without proper planning, and have another person accompany you. ILLNESSES: DATE DISCOVERED Yes No High blood pressure Yes No Diabetes Yes No Heart problems Yes No Cancer (type) Yes No Stroke Yes No Blood clots Other: CURRENT MEDICATIONS Name Amount and frequency taken HERBAL, VITAMIN OR NUTRITIONAL THERAPIES Name Amount and frequency taken ALLERGIES Medication or substance Describe reaction or symptom PAST SURGERIES (check those that you have had) C-section DATE (year) Removal of ovary DATE (year) Left Breast Biopsy DATE (year) Right Breast Biopsy DATE (year) Removal of uterus DATE (year) Tubal Ligation DATE (year) Other: OB-GYN HISTORY Age at first menstrual period. How many pregnancies have you had? How many children have you given birth to? Age at first delivery? Date of last menstrual period? Date of last Pap Smear? Have you taken estrogen or female hormones in the last 10 years? Date Started? Date Stopped? SOCIAL HISTORY Skills (Occupation) Relationship () Where do you currently live? City: State: Do you smoke cigarettes now? Yes No Have you smoked in the past? Yes No When did you start? Date: When did you quit? Date: Do you drink alcohol? Yes No Quantify FAMILY HISTORY Is there anyone with breast cancer in you blood family? If so, list them by their relation to you, their age and when the cancer was found. Relation: Age when cancer was discovered Age at Death Are there any women with ovarian cancer in your blood family? If so, list them by their relation to you, their age and when the cancer was found. Relation: Age when cancer was discovered Age at Death Fathers age Alive? Yes No Cause of death Age at death Mothers age Alive? Yes No Cause of death Age at death Brothers: Sisters: Age Alive Illnesses Age Alive Illnesses Children: Race Ethnicity: Age Sex Health American Indian/Alaskan Native Hispanic or Latino Asian Not Hispanic or Latino Native Hawaiian / Pacific Islander Black or African American White HEALTH REVIEW (last 3 months): GENERAL: YES NO Weight change, greater than 5 lbs? Persistent fatigue: SKIN: Any new skin rashes, lumps or bumps? Hot flashes? EYES: Recent vision change? MOUTH: Sore throat? Sore mouth? NECK: New lumps? Thyroid problems? LUNGS: Cough? Shortness of breath? HEART: Chest pain? Ever been told you had a heart murmur? Abnormal EKG? GASTROINTESTINAL: Nausea or vomiting? Constipation? Change in bowel habits? Change in appetite? Any liver or colon problems? GENITOURINARY: Problems with urination? Vaginal dryness? JOINTS / EXTREMITIES: Any bone or joint pain or stiffness? Arm swelling / lymphedema? Ever had a blood clot? NEUROLOGIC: Have you ever had a seizure? Do you have weakness of an arm, leg or other part of your body? BLOOD: Any history of anemia or blood disorder? PSYCHOLOGICAL: Have you ever been treated for depression or anxiety? Did you have any of these in the past year? Fall. Road traffic crash. Assault. Any type of trauma. Any type of harm. Past medical history Questions to ask about previous medical history General question: Have you suffered from any previous illness? Medical Ask about childhood illness and immunization Have you had ______ or whooping cough? Have you ever been found to have high blood pressure? Have you had rheumatic fever? Have you ever suffered from epileptic seizures? Do you get asthma (episodic breathlessness, usually with wheeze)? Have you suffered from anxiety or depression? Do you have diabetes? Surgical Have you had any operations in the past? Obstetric (where appropriate) Female Have you had any pregnancies? Were they normal? Were there any complications such as hypertension and toxaemia, diabetes, Caesarian section? You may find the mnemonic THREAD helpful: Tuberculosis Hypertension (myocardial infarction and strokes) Rheumatic fever Epilepsy Astham, anxiety and arthritis Diabetes and depression Questions to ask patients about their general health: Cardiovascular and respiratory function Do you have a cough? Do you cough anything up? Have you ever smoked? If so what, how many, and for how long? Do you get short of breath? Do you wheeze? Do you get any chest pain? Do your ankles swell? Gastrointestinal function Has there been any change in your appetite? Has there been any change in your weight? Have you suffered from nausea or vomiting? Has there been any change in the character or frequency of your bowel movements? Has there been any change in the colour or consistency of your stools? Have you had any bleeding? - while vomiting (haematemesis) or rectally? Genitourinary function How often do you pass urine? Do you have pain or burning on passing urine? Do you have pain in the small of your back (renal angles)? Is there any blood in your urine (haematuria)? Do you have any sexual problems? Specific questions for men Do you have any penile discharge or venereal infection? Do you have any difficulty starting to pass urine (hesitancy or urgency), maintaining the flow of urine (poor stream), or stopping the flow of urine (terminal dribbling)? Specific questions for women Do you have any vaginal discharge? When did your periods start? Are your periods irregular? How often do your periods occur and for how long do they last? Do you have heavy bleeding (menorrhagia) or do you pass clots during your period? When did your periods stop (menopause)? Have you had any bleeding since your periods stopped? How many children have you had and when did you have them? Did you have any complications during any pregnancy? Musculoskeletal function Have you any weakness in your arms or legs? Do you have any stiffness in your joints or spine? Do you have pain in your joints or spine? Neurological function Do you have any headaches? Have you had any blackouts? Have you had any fits? Have you had any dizziness (feeling of instability or rotation)? Do you get ringing in your ears (tinnitus)? Do you get abnormal sensations or tingling in your hands or feet (paraesthesia)? Have you noticed changes in your sense of hearing, smell, taste, vision? Have you any incontinence of urine or stools? Do you get depressed? Do you get anxious? Drug history and allergies What drugs, homoeopathic and herbal medicines and/or health foods do you take? - and in what dose? What other therapies do you have? - Physiotherapy? Occupational therapy? Malaria prophylaxis? Do you have any allergies? Have any medicines ever upset you? Family history Are your father, mother, brothers, sisters alive? - If they have died, at what age did he/she/they die? What did he/she/they die of? Do they have any current illnesses? Do any illnesses run in your family? Social history Who is at home with you? Are you single, separated, widowed or _________? Is your partner healthy? How many children have you got? Are your children healthy? What is your occupation? Do you smoke? - If so, how may per day/week? Have you ever smoked? - Why did you give up? Do you drink alcohol? - If so, how many units per day/week? Have you been abroad? - If so, where? Do you have pets? If mobility is a problem: What is your home like? Do you have to manage stairs? What facilities have you got? |