CONSULTATION

1. Demographic data
2. Name, age,dob and sex
3. Race/religion
4. Occupation

• . Presenting or chief complaints
• . History of present illness – with analysis and leading questions (with details of investigations, treatment received and response)
• . History of past illnesses
• . Family history (blood relatives)
• . Personal and social history
  1. Occupational history (sedentary/desk job or active job requiring travel, physical labor etc.). Ask about present and past occupational history.
  2. Habits (smoking, alcohol, drugs, exercise etc.)
  3. Allergy to drugs
  4. Marital status
  5. Menstrual and obstetric history

(in women)

1. Number of children
2. Social status

• . Dietetic history

.  Lifestyle