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PLAN OF CLINICAL HISTORY

1. GENERAL INFORMATION
1. Surname, first name:
2. Age:
3. Sex
4. Marital status:
5. Home address:
6. Place of work:
7. Profession:
8. Date of entrance to the clinic:
10. Date of discharge:
9. Who sent the patient:
12. Hospitalization (planned, emergency):
13. Diagnosis of the sending institution:
14. Entering Diagnosis
15. Clinical Diagnosis:
Main:
Complications:
Additional diseases:

2. COMPLAINTS
This section begins with a medical history listing major complaints that have bothered the patient at admission and were the reason for seeking medical attention or reason for hospitalization. With detalisation of each complaint.
After identifying of main complaints all other complaints are listed.

3. HISTORY OF PRESENT ILLNESS (Anamnesis morbi)
This section details in chronological order and describes all the features of development and course of illness from the time of first symptoms until present.
Description of disease should always start with clarifying following points:
1) Characteristics of illness:
- Time of occurrence (month, year and age) and duration of illness (how many time-feels sick);
- Initial symptoms of disease (first signs of illness and details of their specific features);
- Factors that could initiate the disease (heredity, poor nutrition, infections, life style, stress, etc.);
- Treatment and efficiency of it.
2) Indicate complications (in DM acute and late), time of their manifestation and treatment of complications.
3) Frequency of observations by a doctor,date of last hospitalization.
4) Maintenance therapy with the name of drugs, their dosage, efficacy, side effects, duration of admission (either permanently or occasionally), point if treatment is carried out uncontrollably like self-treatment.
5) Indications for present hospitalization (to detect diagnosis, unefficacy of treatment, progression of disease, occurrence or progression of complications requiring hospital treatment, preparation for surgery, etc.).
Curator must carefully examine available patient's medical records from other clinics. Pay attention to the previously established diagnoses, and data of objective inspection, conducted research and treatment, efficacy of treatment (a positive dynamic or absence of it), the doses and combinations of a number of pharmacological drugs (steroids, antihypertensives, etc.).

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