Family History and Heredity

I. INQUIRY (INTERROGATIO)

PERSONAL DETAILS (IDENTIFICATION DATA)

Full name of the patient (surname, first name and patronymic name)

_____________________________________________________________

Date of birth __ __ _____________ __ __ __ __

Age _________ (full years)

Home address: Smolensk region, town ______________, st. ______________, house № ________, flat № _______.

Place of employment __________________________________

Occupation __________________________________

Date of patient’s hospitalization __ __ _____________ 2005

Date of examination by student __ __ _____________ 2005

2. PATIENT’S COMPLAINTS

Complaints at the moment of admission to the hospital:

Pains: questions:

- Localization (main site)

- Radiation

- Character

- Severity

- Duration

- Frequency and periodicity

- Special times of occurrence

- Aggravation factors

- Relieving factors

- Associated phenomena

Complaints on the day of examination by the students:

Sleep: not broken; changed (insomnia, falling asleep with difficulty, frequent awakening, early awakening and troubled sleep), the increased drowsiness in the afternoon.

Appetite: not changed, increased, reduced, poor, loss.

Stool

Frequency: _____ times per day, _____ times per week, 1 time per _____ days

form (formed, unformed, pappy)

consistence (hard, soft, watery, liquid)

colour of faeces (brown, yellow, black, grey)

pathological admixtures in faeces (mucus, blood, pus, undigested food)

with/without tenderness of defecation

Urination

Frequency _______ times a day (24 hour), during daytime _____ times, during night time ______ times

volume _____________ ml

tenderness (pain, difficulty)

night urination

colour of urine (light/straw/intense yellow, deep/intense brown, “meat waste”, tea-coloured)

HISTORY OF PRESENT ILLNESS (ANAMNESIS MORBI)

Patient considers that he has been ill since ________________ when

Patient was admitted to the ____________________ department of Smolensk regional hospital at the

PERSONAL HISTORY (ANAMNESIS VITAE)

Family History and Heredity

Patient was born in __ __ _____________ __ __ __ __ in ____________________ in the family of _____________________.

He was _______ by birth from _______ (number of children).

Mother was __ __ -year-old, father was __ __ -year-old at the moment of his birth.

He started to go at the age of ________.

He started to speak at the age of ________.

Patient had (not) any delay in his physical and mental development.

He entered school at the age of ________, graduated (primary, secondary, high) school at the age of ________.

He entered _______________ institution, academy, university, technical school, college in __________, graduated in _________. He got the profession of _________________.

He served in army, navy in _________ years.

His occupation was _________________and now ______________ is. He did not work _________________ due to _________________________

He changed the places of residence

Patient is married, has _________ children of age.

Family diseases and heredity (and specify who from patient’s close relatives suffered from):

Diabetes

Hypertension

Tuberculosis

Apoplexy

nervous diseases

mental diseases

cancer

other significant diseases

Patient’s parents are alive, died of _____________ at the age of __________

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