I. GENERAL INFORMATION (IDENTIFICATION DATA)1
1. Surname, first name.
2. Age.
3. Sex.
4. Place of Work.
5. Profession.
6. Occupation.
7. Home Address.
8. Date of admission to the clinic.
In case history nationality of the patient is not officially mentioned. However, national and racial identity of the patient may have some value in the diagnosis and treatment (see comment 1).
1 For detailed information on the topic «Anamnesis» check web-site: www.oslopov-kazan.ru.
II. MEDICAL HISTORY (ANAMNESIS1)
1. COMPLAINTS AT ADMISSION TO HOSPITAL
Complaints should be divided into main (basic or major) and minor (additional or secondary) with their details.
Main complaints refer to important symptoms of the disease, most typical for that disease, which shows to some extent the localization of the process. Usually these are the symptoms that led the patient to the doctor.
Minor complaints, typically defined as complaints, indicating only to the presence of the disease and reflecting the general state of violation, but not specific to the particular disease (weakness, fever2, etc.), are complaints that are associated with concomitant diseases (not that which currently leads the patient to the doctor).
Complaints must be detailed. Questions given to the patient to explain his complaints, should not be direct (not those to which patients answer in algorithm «yes-no») but indirect (those to which the patient picks up terms, definitions, describing his feelings) (comment 2). One should be very careful in formulation of clarifying questions, make sure that they do not become a suggestive3 questions.
Complaints, depending on the primary lesion of various organs, may be as follows.