Patient History Form: Fill & Download for Free

This is the biggest fear I or, for that matter, any medical student faces in the clinical exam in India.(Based on true events)The scenario: you are giving one of the toughest exams of your life. Facing an examiner you have never seen and probably answering questions you have never heard before. (If it is more of the latter, God save you).The patient's history is taken in rapid detail and examination is completed. 45 minutes is all you get. The patient is either a regular fare at such exams with a chronic disease like SLE or cardiac valvular disease, visiting exams for the past 10 years, and knows about his case probably more than you. Or, he is a complete newbie and has been thoroughly irritated by the multiple examinations in the last 2 days of the exam.Then, you take your clumsily written history sheet to the grim, moustachioed, frowning and forbidding examiner, who looks like he last smiled on the day of his wedding.Event 1:Examiner: what is your case?Student: s..sir, pain in the right hypochondrium for last 3 months.Veteran patient: but sir i have pain for last 6 months.(Please understand that you are not at fault here. Some veteran patients have their own bit of fun during the exams).Student: exactly sir! Pain for last 6 months which has exacerbated for last 3 months. I was coming to it in history of present illness!Veteran patient and student exchange glances.Event 2Examiner: history please.S: a 30 year old male with pain in the right iliac fossa…. Completes history…E: (to the patient) so where is your pain?Irritated Patient: (pointing to epigastrium) here sir!Examiner frowns and looks at you like you have just asked for his kidneys….S: (to the patient) but isn't that pain mild? Didn't you say it is mainly gaseous bloating? Weren't you having severe pain for the last 1 month here (pointing to right iliac fossa)? If you don't tell sir everything properly, your treatment will erroneous! Remember! Tell sir where you exactly have the pain! ( Points to the iliac fossa while asking)Irritated Patient: actually sir. He is right sir. I have pain here but some bloating here too. All these boys have been pressing my stomach for the last 2 days.(You breathe a sigh of relief as the examiner's frown decreases by 20 percent).So, to summarize, there is really no quip you can use to salvage a history changing patient. You are giving the exam like your life depends on it. Rather than a comeback, you need a life saver and quick thinking. My experience/suggestions are:Never change the patient's history. Ever. Period. Try to fit the reasoning to the history. Not vice versa.Never argue with the examiner. What he says is gospel fact. You must accept that you are suresh if he calls you that, even if you are ramesh. Just make sure he gets your roll number right.Reinforce the patient's history during your examination. Repeatedly ask and tell him, while pointing to the area that he has spoken about. This will decrease chances of a change.Never try to act smart with the examiner. He holds the pen that passes the judgement to hang you.Be confident. Never get flustered and stammer.Respect the patient and respect his body. Examine him gently. Make him comfortable and always treat him well. He is your biggest teacher. The better your rapport with the patient, the lesser the chances of a surprise during the presentation.Impress on the patient that a correct history will ensure correct treatment. Wrong history will confuse the big doctor from outside the state. (Doesn't work on veteran patients)Don't get afraid. The examiner can sense your fear. He can feed on it. Literally. The patient too loses confidence in you.One thing that i firmly believe is that case presentation is an art form of the highest degree. You may be an excellent student with wonderful memory, but it can all go south during your case!Best of luck!

Only one? Let me give you two practical project ideas1. Tidying cablesNot only power lines, but also internet, phone, and another cables which very annoying to see and quite dangerous.Not only overhead cables, but also the underground ones:I got idea from my friend who used to work in Japan(Abdurrosyid Handoyo), that this can be solved if we have one company to be responsible for every cabling system. It’s responsibility is starting from cable plan, execution, maintenance, troubleshoot, and also cut any illegal cable. So it covers security and tidiness. This can’t be done by regulation only, since we will need to put effort in surveillance and law enforcement. Regulation only will make the cabling system a bit safer, but not tidy.No more drains clogged by unknown cables skin:You’ll know which hotline you have to contact if see something like this:My excuses for not doing this are:I have lost my mind in low current electrical engineering, especially electronics.It’s better to be done if the cabling company is formed as “BUMN” (owned by the state), so they have more power and supported by goverment.2. Unification of patient history database across hospitals, medical clinic, and “puskesmas”This is almost done by BPJS or another health insurance. But it only covered for medical treatment or drugs which paid by that health insurance. Outside that, we don’t have centralized patient history database. Once we change the doctor, we need to explain our history by ourself.It needs dedication to convince every medical clinic to put aside their own business. I can’t do this now since it is outside my current capability. Let alone convincing medical clinic/hospitals, I forgot how to design database…

Your health insurance is not interested in keeping your medical records. They keep only records pertinent to payment. The reason you have to fill forms over and over is that without this physicians will not get paid. 80% of paperwork is used to justify payments. New electronic system is only electronic data entry that has been moved to physician offices so insurance companies does not need to employ people to do it, control veracity of the data etc. right now, data are entered in physician office, their are fed into giant database in insurance companies. Each insurance company analyze and mind the data for billing and audit purposes. Note that there is very minimal transfer of medical information to insurance companies. Medical notes stay at physician office. The only information transferred is bill ( read code for diagnosis and code for payment).