Sample Proforma
Knock the door thrice,
(smiling patient – not in distress - GIVE SMILE not smiing- in distress – NO SMILE, DO NOT SIT)
Good Morning Mr. / Miss._________ I am Dr. Patel. I will be your physician today. Today I will ask you some questions and perform a physical exam. ok?
Are you comfortable in this room? Let me make you more comfortable by draping you. (If says no - Is there anything bothering you?) (Drape the patient) (While draping …) During our conversation if you have any concern then please let me know. Hope you don’t mind if I make some notes while asking you questions.
[SILENT PATIENT (anxious, sad- crying, depressed) - Stay silent for few seconds. Put a hand on her shoulder & say, “Mr.__________You seems to be upset. Will you please share it with me? I am here to help you”.]
Chief complain -
So, Mr. _____________ “How can I help you?”
Oh! I am sorry to hear that. Can you tell me more about it?
History of present illness
O D P L I Q O R A A A
When did it start? (When did you first notice it?) (What were you doing at that time?)
Do you know anything which may be responsible for your ……? (Do you remember anything which might have brought it?)
So as you told me that you have………….. Then has it been remaining same or getting worse?
Is it continuous or comes and goes? (if intermittent- How often does it occur? How long does it
last for?)
What does make it better?
What does make it worse?
Do you have any other complains besides ….?
(CVS/RS – Cough, Breathlessness, Chest pain, CVS – Palpitation, Sweating)
(ABD-Pain in abdomen, Bowel- bladder, Jaundice)
(CNS – Headache, Dizziness, Seizures, Sensations, Weakness, Difficulty - vision, hearing, speech,
walking, Loss of consciousness)
PAIN- (Chest, Abdominal, Headache, Joint pain)
- When did it start?
-
So as you told me that you have………….. Then has it been remaining same or getting worse?
-Is it continuous or comes and goes? (if intermittent- How often does it occur? How long does it
last for?)
Location - Can you show me the exact site with your finger? (except vagina/penis, anus, back –
where do you feel it? )
Intensity –How would you grade your pain on a scale of 1 -10, if the 10 is the worst pain of your
life?
Quality - How does it feel like? (I mean sharp, dull, throbbing, burning)
Radiate – Does it move anywhere?
Alleviating factors – what does make your pain better?
Aggravating factors – what does make your pain worst?
GENERAL - Do you have any fever, nausea, vomiting?
a.
Fever
i. Do you have any fever?
ii. Is it continuous or it comes and goes? (if intermittent -How often does it occur? How long
does it last for?)
iii. Do you have any chills? Any night sweats?
iv. Have you measure your temperature?
b.
Nausea
- Do you feel nauseated?
c.
Vomiting
i. Did you vomit?
ii. Can you estimate the amount of it? (Cup full)
iii. What was its color?
iv. Was there any blood in it? (If Yes - How much?)
(A.) RS + CVS
Do you have any cough? Short of breath? Chest pain? Racing of your heart?
a.
Cough
i. Do you have cough?
iii. Sputum- Do you bring up anything with it?
iv. Quantity - Can you estimate amount of it?
v. Color - What is its color?
vii. Blood – Is there any blood in it? (If Yes - How much?)
viii. Smell – Is it foul smelling?
b.
Breathlessness
i. Do you have short of breath?
iii. Relation with exertion - When do you get SOB? [walking, climbing upstairs]?
How far can you walk on ground level before you have SOB?
How many steps can you climb before you have short of breath?
iv. PND - Do you have attacks at night?
What do you do to relieve your short of breath?
c.
Chest pain- Do you have chest pain?
L I Q O R A A A
d.
Palpitation – Do you have racing of your heart?
Sore throat
Do you have any Running nose? Ear discharge? Swollen glands in neck? Rash?
(B.)ABDOMEN
Do you have pain in your belly?
Do you have any problem with your urination? bowel movement?
Have you notice any change in color of your skin? Your eyes?
a.
Abdominal pain –
Do you have pain in your belly?
L I Q O R A A A
- is there any relationship with food?
b.
Jaundice
Have you notice any change in color of your skin? Your eyes?
Do you have any itching? Any joint pain?
Have you ever received any blood transfusion? Immunization for jaundice?
(bowel – color of stool, Bladder – color of urine, sexual, alcohol, travel)
(C.)CNS
Do you have any Headache? Dizziness? Jerking movements?
Do you have any Numbness?Weakness?
Do you have any problem with your Vision? Hearing? Speaking? Walking?
Have you ever passed out?
a.
Headache
I. Do you have headache?
ii. L I Q O R A A A
iii. Aura - Can you tell me what happens before your headache?.
1.AnyWatering of your eyes? Any Running nose?
2. Any Unusual lights, sounds, smells?
iv. Neck stiffness - Do you have any stiffness in your neck?
b.
Dizziness
1. Do you feel dizzy?
2. Is it continuous or comes and goes? (if intermittent- How often does it occur? How long does
it last for?)
3. Is there any relation with position? - BPPV
4. Do you feel that the room is spinning around you or you are moving inside the room?
5. Do you hear ringing of bell in your ears? - Tinnitus
6. Do you have any ear discharge?
c.
Seizures
Do you have any jerking movement?
When did it occur last time? How long does it last for?
How often does it occur?
What did happen at that time? Did you pass out? Fell down?
Can you tell me what happened before the attacks?
-Racing of your heart? Dizziness? Unusual lights, sounds, smells?
Can you tell me what happened during the attack?
-jerking movement? – can you describe it? Tongue bite? Frothing from mouth? Loss of
control of urination or bowel movement?
Can you tell me what happened after the attacks?
- numbness, weakness, headache, confusion,?
Loss of conciousness-
Have you ever passed out?
When did it occur last time? How long does it last for?
How often does it occur?
Difficulty in hearing-
On which side of ear, you have problem with hearing?
When did you notice it?
Do you hear ringing of bell in your ears? - Tinnitus
Do you have any ear discharge?
j. Joint pain
i. Do you have any joint pain?
ii. L I Q O R A A A –
iii. Trauma – Do you have any injury recently? (if yes - Do you have any weakness around your joints?) (Nerve injury)
iv. Stiffness/Swelling/Redness – Have you noticed any redness/swelling/stiffness in your
joints? When does it occur? How long does it last for? (RA/OA/AS)
v. Insect bite Have you noticed any insect bite recently? (Lymes) (Travel – Have you traveled recently?)
vi. Rash - Have you noticed any rash in your body? (When did you notice it? Where did it first start? How did it progress? Can you describe your rash?
– pain/ burning, itching, discharge- color , foul smelling)
vii. Photosensitive- Are you sensitive to bright light?
viii. Mouth ulcers – Do you have any ulcer in mouth?
ix. Hair loss- Have you noticed any hair loss recently? (SLE)
x.Do you have similar complains in other joints?
Osteoarthritis (OA) -Mr. _____. Your problem may be due to your aging. So I advise you to do
regular exercise and you should also consider for weight reduction.
PAM HUGS FOSS
Well, Mr. _____ Now I am going to ask some questions about your past medical health. ok?
1.
Past History – Have you ever had similar complain in the past? if yes- Can you tell me more
about it. Do you have any major illness like Diabetes, high blood pressure, high cholesterol?
A. Diabetes?
i. When was it detected?
ii. Do you get your blood sugar checked regularly? What was the last reading?
Iii. Are you taking any medication for it? (No) Can you tell me why it is so?
iv. Which medication are you taking? (No) Do you have any prescription for that right now?
v. Do you take it regularly?
(Vi. Do you have any side effects from it like …?
hypoglycemia – sweating, palpitaion, black out
Polyurea - nocturia, polydypsia, polyphagia, fatigue , weight loss
Fundoscopy)- if follow up
Diabetes
Mr._____ As a concerned physician, I must inform you that high blood sugar may damage your
heart, blood vessels and many other organs.
So I recommend you to get your Blood Sugar checked periodically and take your treatment regularly. You should also consider for soft heeled foot ware.
B. High Blood Pressure?
i. When was it detected?
ii. Do you get your blood pressure checked regularly? What was the last reading?
Iii. Are you taking any medication for it? (No) Can you tell me why it is so?
iv. Which medication are you taking? (No) Do you have any prescription for that right now?
v. Do you take it regularly?
(vi. Do you have any side effects from it like…..?
CCB- headache, constipation, B blocker- depression,impotence, ACE- cough, Diuretics – ototoxhearing
loss, tinnitus
Fundoscopy) –if follow up
Hypertension
Mr._____ As a concerned physician, I must inform you that high blood pressure may damage
your heart, blood vessels and many other organs. So I recommend you to get your Blood Pressure checked periodically and take your treatment regularly. You should also low salt in your diet.
C. High cholesterol?
- Are you taking any medication for that?
Ask specific P/H related to the system.
Obesity
- Do you know anything which may be responsible for this weight gain?
- How is it affecting you life? Ask about height and weight in closure
Thyroid – cold intolerance, hair loss, constipation
CVS-RS, GI, CNS, Metabolic- DM ,Ortho
1. Depression
2. Hypothyrodism
3. Cushing’s syndrome
4. Polycystic disease
5. Sedentary lifestyle
6. family h/o
2.
Allergy – Do you have any allergy? Which allergy do you have? If RS or SKIN –what kind of
allergic reactions did you have?
3.
Medicine –Are you taking any medications (Apart from ….........)?
(Which medications are you taking? Since when are you taking these medications? Why are you taking these medications? )
4.
Hospitalization, Surgery, Trauma – Have you ever been hospitalized before? [for what?]
Have you ever had any surgery before (Apart from….)? any major injury in your life ?
5.
Urination –
Change – Do you have any problem with your urination?
Frequency - How often do you go for urination?
Nocturia - Do you wake up at night for urination?
Urgency - Do you have to rush for urination?
Burning - Do you have any pain during urination?
Do you have any burning during urination?
color – what is its color?
Blood – Is there any blood in urine? Any Pus in it?
Hesitancy - Do you have to wait to start urination?
Straining - Do you have to strain to pass urine?
Flow - How is the flow of urine? I Mean continuous or dribbling
Incomplete evacuation – do you feel that your urinary bag is not empty even after urination?)
Control - Have you ever passed urine without your notice?}
6.
GIT –
Change – Do you have any problem with your bowel movements?
Frequency - How many bowel movements do you have?
Consistency- What is its consistency?
color - What is its color?
Blood - Is there any blood in it? Any pus in it?
Pain - Do you have any pain during bowel movements?
Straining - Do you have to strain during bowel movements?
Incomplete evacuation - Do you feel that your bowel is not empty even after your bowel movements?)
control – have you ever passed stool without your notice?
7.
Sleep –
Do you have any problem with your sleep?
Do you have problem in falling asleep? Staying with sleep? Do you wake up early in the morning?
How many hours do you sleep?
Do you feel refresh when you wake up?
Do you feel sleepy during day? Do you snore at night? If insomnia case)}
Falling- what do you do before going to sleep ? -watch tv, heavy meal
Staying – how often do you wake up at night?
8.
Family History
Well, Mr. ______ Now I am going to ask some questions about your family health. Is that ok?
Does anyone in your family have similar complain?
How are your parents doing? [If died, Oh! I am sorry to hear that. But can you tell me the cause
of their death?]
9.
Gynecological History –
Well, Mizz.______. Now I am going to ask some questions about your female health. ok?
- When was your last menstrual period?
- Are your periods regular?
- How many days are there in your cycle?
- How long does your period lasts for?
- How many pads do you need?
- Do you have any pain during menstruation?
- Have you ever bleed in between the cycle?
- Have you ever undergone PAP smear examination? What was the last result?)
Obstetric History –
How many kids do you have? –If mentioned in hospitalization or surgical h/o then- Apart from)
Have you ever had any abortion? In which month/week of pregnancy? Do you know the reason for that?
10.
Sexual History
Well, Mr. ____, now I am going to ask you some questions about your sexual health.
(Please be assured that whatever you tell, will be kept confidential. Is that ok? )
(Mr. ______, sometimes hidden clues can be found by such kind of information, which may help in your diagnosis. Is that ok?)
a. Are you sexually active? (No) May I know why it is so? Do you have problem with desire-libido, excitement- arousal, erection, ejection, satisfaction?
b. How many sexual partners have you had in last one year?
What is your partner preference? I mean male or female?
c. Do you use any mean of protection? (Does your male partner use condom regularly? Condom? Birth control pills? )
d. Do you use it regularly? (No) may I know why it is so?
e. Have you ever been diagnosed with Sexually Transmitted Disease? Was it cured completely?
f. Have you ever been tested for HIV? What was the result?
g. Do you have any penile / vaginal discharge? Since when? what is its color? Is it foul smelling?
Sexually promiscuous patient with unprotected sex
Mr. ______ I must inform you that multiple sexual partners and unprotected sex may put you at high risk of sexually transmitted so I recommend you to should use condoms each times you have sex. – if male .so I recommend you to insist your male partners to use condoms each times you have sex. – if female STD… is sexually transmitted disease which may acquired from your partners So it is needed to test and treat all of your sexual partner as well otherwise you will be at risk of contracting infection again.
You should also avoid sex till the treatment is completed.
I recommend you to/ should use condoms each times you have sex.- if male
I recommend you to insist your male partner/s to use condoms each times you have sex. – if female
11.
Social History / Personal History T A D E R O T S (TOBACCO, ALCOHOL, DIET-APETITE, WEIGHT, RECREATION DRUG, OCCUPATION, TRAVEL, STRESS)
Well, Mr. _____ now I am going to ask some questions about your personal habits. Is that ok?
Smoking
i. Have you ever smoked? Since when?
ii. How many packs per day do you smoke?
Alcohol
i. Have you ever drink alcohol? Since when?
ii. How much alcohol do you drink?
(
Cut – have you ever tried to cut down your drinking?
Annoyed –Have you ever annoyed by criticism of your drinking?
Guilty – Have you ever felt guilty about your drinking?
Eye opener – Do you take alcohol in early morning?) – if binge drinking Drugs
Have you ever take any recreational drugs? Since When? How do you take it? I mean do you inject or smoke it? Smoking / Alchohol
Mean while I strongly recommend you to quit smoking and/or alcohol as it can damage your heart, lungs/liver and many other organs So are you ready to quit (the smoking/alcohol)?
(yes ) I am glad to hear that. We have excellent support group, who will help you in this matter.
I will give their contact number to you. Is that OK?
(no ) I can understand that. But whenever you are ready to quit, then I will be here to help you.
Please collect my contact number from my nurse outside.
(I had tried quite but it didn’t worked- Mr. _____ I can understand that. It happens to most of the people. If no smoke/alcohol – I appreciate that you are taking good care of your health and also hope that you will also continue in future. If quit - I am glad to hear that you have stop ….. And also hope that you will not take it in future also.)
{Diet Are you on special diet? (diabetes, kidney failure)}
Appetite
Is there any change in your appetite?
Is there any change in your weight ?( How much? Over what period of time?)
What do you do for living?
Have you traveled recently?
Do you exercise regularly?
{Do you have any stress in your life? May I know with whom do you live with? How is your relationship with them? (elder) Do you have any contact with person with similar complain? ( ill contact exposure – infections like TB, Pneumonia, diarrhea etc.)}
SO.. AS YOU SAID YOU HAVE....
PHYSICAL EXAMINATION
Well Mr. ….Now I need to examine you. Before that would you like to tell me anything else?
Ok, Let me wash my hands first. Excuse me for a while. (Ask about work, travel, exercise)
Can I proceed with your examination?
If pain occurs- I AM SORRY, I WILL NOT REPEAT THAT AGAIN.
Patient resisting for physical examination
“Mr._____, I can understand your concern. But the physical examination I want to do is very important to determine what is causing your complain. I will be quick and gentle as possible. And I will inform you whatever I am going to do.”
If ask for pain medication-
“Mr._____, I can understand your concern. But right now giving medication may harm you. Once I find out exact reason for your pain, I will able to give you something to feel you comfortable.”
General Examination – not in HEENT and NEURO
("PICKLE" –( Pallor, icterus,) (Cyanosis, Clubbing, Koilonychia,) Lymphadenopathy and Edema Feet" )
Let me start with your eyes.
Can you please look up? Look down? Thank you.
Please open your mouth. Stick out your tongue. Say Aaah for me. Thank you. (9,10)
I am going to check your neck for any swollen glands.
Please show me your hands. Your nails. Let me check your pulse. Thank you.
Well. Mr.........Now I need to examine your legs. For that I need to raise your drape for me? Is that ok? Thank you. Let me cover it again.
HEENT
Head – I am looking at your head for any swelling.
Face – I am going to press on your face. Let me know if it hurts. (sinus tendernees. - frontal and maxillary)
Eye – vision acuity, EOM {PERLA, Fundoscope - (dim light) – HTN, DM Follow up, vision problem}
Please cover your Right eye- can you please read the smallest line you can? Thank you.
Now cover your left eye. You may uncover your eye.
Can you please follow my finger without moving your head? Thank you.
{Now I am going to check your vision with the instrument called Fundoscope. Excuse me for a while.
3. Now I am going to throw light in your eyes. Can you please see at that wall?
4. Fundoscopy - Now I am going to check your eyes deeply. }
Ear – I am looking at your ear for any redness.
I am going to press your ears. Let me know if it hurts.
Now I am going to check your ears with the instrument called Otoscope. Excuse me for a
while. (change the speculum)
{ 8 nerve - Deafness
Weber- Now I am going to put this tuning fork on your forehead. Can you hear it? Does it sound same or different in both ear?
Rinne- Now I am going to put this tuning fork on front and back of ear. Then tell me which one sounds better?}
Nose – I am going to check your nose for any discharge.
Throat - Please open your mouth. Stick out your tongue. Say Aaah for me. Thank you
Neck – I am going to check your neck for any swollen glands.
Now I am going to check gland of your neck which is called thyroid. Can you please swallow for me? thank you.
Respiratory system
Now I am going to examine your chest and your heart. For that I need to untie your gown. Is that ok? Let me help you.
Inspection –
Now I am looking at your chest for any abnormality.
Palpation-
Now I am going to press your chest. Let me know if it hurts. (m - 4, f - 2)
Can you please say 99 repeatedly, when I touch your chest? (m - 4, f – 2)
Now I am going to check your breathing movement. Can you please take deep breaths for me?
(m – 1+1, f – 1+1)
Now I am going to feel your heart beat.
Percussion
Now I am going to tap on your chest. (m - 4, f – 2)
Auscultation – (keep stetho for full inspiration and expiration)
Now I am going to listen to your chest. Can you please take deep breaths for me? Thanks. You may relax now.
(m – 1+2, f – 1+2)
Now I am going to listen to your heart. Can you please stop your breath for a while?
(Auscultate – aortic- pulmonary- tricuspid- mitral areas.) Thank you. You may relax now. Let me tie your gown.
CVS
(check radial, dorsalis pedis and edema in general examination)
Now I am going to examine your chest and your heart. For that I need to untie your gown. Is that ok? Let me help you.
Inspection –
Now I am looking at your chest for any abnormality.
Palpation-
Now I am going to press your chest. Let me know if it hurts. (m - 4, f - 2)
Now I am going to feel your heart beat.
Auscultation
Now I am going to listen to your heart. Can you please stop your breath for a while?
(Auscultate – aortic- pulmonary- tricuspid- mitral areas.) Thank you. You may relax now.
Now Can you please lie down for me? Let me help you. Thanks.
Now I am looking at your veins in your neck ( jvp)
Now I am checking your pulse in your neck. ( palpate and auscultate for carotid bruit )
Now I am going to listen to your heart. Can you please stop your breath for a while?(auscultate 4 areas.) You may relax now.
Now you can sit up. Let me help you.
Now I am going to listen to your chest. Can you please take deep breaths for me? Thanks. You may relax now. (m – 1+2, f – 1+2)
Let me tie your gown.
Abdomen – P/R EXAMINATION – in closure
Now I am going to examine your belly. For that I need you to lie down. Let me help you. Thank you. (pull foot rest out)
Can you please raise your gown for me? Let me help you.
Inspection
Now I am looking at your belly.
Auscultation
Now I am going to listen to your belly.
Percussion
Now I am going to tap your belly.
Palpation
Can you please bend yours knees for me?
Now I am going to press your belly. Let me know if it hurts.
Now I am going to press your belly deeply. Can you please take a deep breath for me?
Now I am going to press your belly and then release it immediately. Let me know if it hurts on
pressing or releasing? - Rebound tenderness
Thank you. Now you can cover your gown. Let me help you.
Ohk, Mr.______. Now I need to examine your back. For that I need you to sit up. Let me help you. (push foot rest inside). Now I need to untie your gown. Is that ok?
Now I am going tap your back, let me know if it hurts. - costovertebral tenderness
Let me tie your gown.
Appendicitis
Psoas sign – Can you please move your knee towards your chest against my hands? And Let me know if it hurts. (flexion of hip)
Obturator sign –I am going to move your knee. Let me know if it hurts. (internal rotation of hip)
Rovsing sign –I am going to press your left side of belly. Let me know if it hurts on right side.
Cholecystitismurphy's
sign- I am going to press your belly. Can you please take deep breaths for me? And
Let me know if it hurts?
CNS
MMSE – Depression, Dementia
Okay, Mr. _____ now I am going to ask you some questions to check mental function.
1. What is your full name? What is the date today? Where are we right now?
2. Now I am going to tell you three words. I want you to repeat them immediately and after
some time, is that ok?………….cat, apple and table
What is the importance of 4th July? - (Independence Day)
3. Can you please count back from 7?
4. What would you do, if you see your friend’s house on fire? - (call 911)
5. Can you please repeat those three words for me?
Cranial nerves
Now I am going to check your nerve function.
Do 2, 3-4-6, 7, 9-10-12, 5, 8, 11
II - Please cover your Right eye- can you please read the smallest line you can? Thank you. Now
cover your left eye. You may uncover your eye.
III, IV and VII - Can you please follow my finger without moving your head? Thank you.
VII- Can you please raise your eyebrow, smile for me? Thank you
V -can you please clench your teeth for me?
VIII - Can you please close your eyes? Can you hear this?
IX, X, and X, XII- Please open your mouth. Stick out your tongue. Say Aaah for me. Move Side to
side. Thank you
XI -Can you please shrug your shoulders against my hands?
MOTOR
Now I am going to check your muscle strength.
Upper limb
Please hold my fingers tightly and pull it towards your side and push it towards my side. Thank
you.
[Wrist – Can you please pull up? Push down? Thank you.
Elbow – Can you please pull in? Push out? Thank you.]
Lower limb
Knee – Can you please kick out? Pull in? Thank you.
[Foot – Can you please pull up? Push down? Thank you.]
REFLEX
I am going to check your jerks. Biceps, (Brachio radialis) Knee, (Ankle)
SENSORY
Now I am going to check your sensation.
See this is sharp and this is dull. Now please close your eyes? And tell me which one is sharp
and which one is dull?
4 face areas (forehead, cheek) , arm(hand) leg (foot)
Cerebellar test- Now I am going to check your balance.
Finger nose test – Please take your right finger. Now touch my finger and then touch your nose
repeatedly. Now repeat it with your left finger.
Gait - Now I need you to walk few steps for me. Let me help you (pull out foot step). Please be
assure that I will not let you fall down.
Now please turn and come back.
Romberg test – Please stand with put your feet together. Now close your eyes.
Special test-
Kerning’s sign- Can you please bend your thighs and knee. Now I am going to move your knee.
Let me know if it hurts.
(flex both knee and hip, then try to extend the knee only.)
Brudzinski’s sign- Now I am going to bend your neck. (When you flex the neck, there may be
flexion of hip and knees)
SPINE
Now I am going to check your back. For that I need to untie your gown. Is that ok? Thank you.
inspection
Now I am looking at your back for any abnormality,
palpation
Now I am going to press at your back. Let me know it hurts. (cervical, thoracic, lumbar, sacral.)
range of motion
Now I am going to check movement of your back. Can you please bend forward, backward,
sideward, move side to side? – flexion, extension, lateral flexion, twisting.
gait
Now I need you to walk few steps for me. Let me pull out foot step for you.
Now please turn and come back?
Motor, reflexes, sensations
lower limbs
Pulsations
SLR
Closure
All right, Mr._____, thank you for you kind co-operation. First of all, let me summarize.
As you told me that you have………….is that right?
According to the information I got from you and from the examination, I am considering the
possibilities like you may have….. But to confirm the diagnosis, I need to run some tests like blood test and scanning of your________ . if ABD- P/R Exam . if gynec – Pelvic Exam . As soon as I get the results, we will meet again. And at that time I will explain you in the details and we will also discuss the treatment options. ok? Counseling –smoking, alcohol, STD ( If not done previously) Have you understand what we discussed today? Do you have any questions for me? No- If you have any question later on, you can call me at any time. Ok, Mr._____It was nice to meet you. Bye. Take care. (shake the hand with smile and leave the room )
Challenging questions-answers
So doc I have....?
Well Mr....... I can understand your concern, but first of all I would like to do physical examination and run some tests. Once the test results available, I will be in better position to
tell more about it.
(Well Mr.......From complain you have told there is less chance of......... but first of all… Well Mr......, It may be one of the possibilities. But there are also other conditions which mimics
your complains. So first of all….)
Cancer?
Mr….I can understand your apprehension. Some cancers are hereditary. But that does not
mean that you will get it.
So am I going to die?
Mr….I can understand your apprehension. But I want to assure that here you are in the safe
hands and we will do our best to feel you better.
Am I going to get better?
Mr…. I can understand your concern. There are number of conditions which mimics your
complains and many of them are treatable.
Angry
I am sorry that I keep you waiting. Actually we had some unexpected delay with earlier patients. But right now I am here and I will focus on you and your concerns. And I will also keep
in mind that it will not happen again.
[Over talkative patient- “Excuse me Mr______. I can understand that those issues are important to you. But right now I want to focus on you and your current problems. ” come to the problem where stop.
If want to ask again -“I am sorry. Can you please repeat it again what you have just said?”
if time is over - "Oh. I am sorry. We have an emergency. I have to leave. I will be back as soon I can."]
PSYCHIATRY
General
Mr._______ you seem to be upset. Will you please share it with me? I am here to help you.
Mr._________ I really want to help you and for that I need to understand your problem. Can
you please tell me what happened to you? (Is there anything which I can do to feel you better? Or I will do everything which I can to feel you better.) I want to die doctor – I can understand that its hard time for you. But running away from the problem is not the solution. We can deal with it to gather in much better way.
Etiology –
Is it associated with any event?
Any emotional problem? Any family problem? Any financial problem?
Do you have trouble in adjusting with temperature? Have you notice any hair loss?
support – May I know Whom do you live with?
Is there any one for your help when needed?
DEPRESSION (FACE SLIPS)
Feeling of guilty – Do you feel guilty about anything?
Appetite – Is there any change in your appetite, weight?
Concentration – Do you have any difficulty in concentrating? Memorizing things?
Energy – How is your energy level? (Sleep –Libido –)
Pleasure level – Are you able to get interest in those activities which you were enjoying in the past?
Suicidal ideation - Have you ever thought about hurting yourself or ending of your life? Do you
have any plan for that? Have you ever tried to do so?
Hallucination – Do you hear anything that other people can’t?
Do you see anything that other people can’t?
Delusion –Do you have belief about yourself or world that other people find odd?
Do you have any belief that other people are trying to harm or control you?
Counseling
Your problem is common in our society and you are not alone.
You can call me at any time whenever you feel worse.
We have excellent counselor and support group who will help you in this matter. I will give their
contact numbers to you.
DEMENTIA
Do you have difficulty in performing daily activities? like remembering names, phone numbers, keys, turn off stove, ?
DEATH–Do you need any help in getting dressed [dressing]? Eating [eating]? moving from your
bed to chair [ambulation]? Going to bathroom [toileting]? [ Have you ever had any accident with urine or bowel movement [hygiene]?]
SHAFT–Do you need any help in shopping [shopping] ?, cleaning your house [house keeping] ?
Managing your money [accounting] ? cooking [food preparation] ? moving from one place to other [transportation] ?
Counselling
I need your permission to talk with your caretaker who can help me with your diagnosis.
I would also like you and your care taker to meet with social worker who will suggest you about
home safety measures.
Meanwhile I will remain in contact with you and your family to provide help and support.
ABUSE
support – May I know Whom do you live with?
How is your relationship with them?
Well Mrs. I am concern about your safety and I want to make sure that you are not victim of abuse.
Safe - So are you safe at your home?
Well Mrs. I want to assure that whatever you tell, will be kept confidential.
So can you tell me what exactly happen to you? How often does it happen?
(So does anyone in your life have hurt you physically? Emotionally?)
Afraid of – Are you afraid that it will happened again?
Family aware - Are your parents / friends are aware of your current condition?
Emergency plan- Do you have any emergency plan to leave your home?
A- Does your husband drink alcohol?
D- How is your mood whole a day?
How many kids do you have? Are they being abused or threaten?
Counseling
I am concern about your safety. I will be here for your help and support.
Please assure that whatever you have told will be kept confidential.
I will give you contact numbers of social support group and shelter where you can go for help whenever needed.
Moreover I must inform child protective services if your child is being abused.
Pediatric case (mostly a telephone case)
Good morning. I am Dr. Patel. I am physician in this hospital. May I have your name please?
(May I know to whom I am talking to?)
Ok. Miss…..today I will ask you some questions about your child’s health is that ok?
During our conversation if you have any concern then please let me know.
So Mrs.______, How can I help you today?
Oh I am sorry to hear that your child has……………….
Can you tell me more about it?
Onset – When did it start?
Progress - How did it progress?
Frequency – how many bowel movements does he have?
What is its consistency?
What is its color? Was there any blood in it?
How does his skin looks like? Is it shining or dull? How many times does he urinate?
Has he traveled recently?
Is there any relationship with any food?
[Does he attend day care center? Is there any ill contact over there?
How does he look like? Playful, tired, irritated?
How does he cry like? Vigorous, weak?]
[Does he have any fever? Vomiting? Rash?
Cough, Fast breathing? Running nose? Ear discharge? Difficulty swallowing
Shaking?
Do you think that he has pain in……….?]
Well, Mrs. _____, now I am going to ask some questions about …...'s Past Medical Health. Is
that ok?
P/H – Did he have similar complain in the past?
Did he have any major illness like jaundice?
Does he have any allergy?
Are you giving any medications to him?
Did he ever been hospitalized before?
Did he have any surgery?
Does his have any problem with urination? Bowel movement? Sleep?
Pre natal ,natal postnatal History
All right, Mrs. …..Now I am going to ask about ….........'s birth and your pregnancy. Is that ok?
Did you get routinely checked during her pregnancy?
Was there any problem during pregnancy?
Were you smoking during pregnancy? Taking alcohol? Recreation drug? Medications?
What was the mode of delivery? Was it normal delivery or cesarean?
Was the baby full term? If no- At which month of pregnancy did you give birth ?
Was there any problem during delivery? After delivery?
When did he first cry after delivery?
When did he start his first feeding?
When did he pass his first stool?
Feeding history
Have you ever breast fed your child?
When did you start to give solid foods?
What does he eat now?
Are you giving any multivitamins?
Is there any change in his appetite? Weight?
Developmental history
Is he growing normally?
Is his current weight and height appropriate to the growth chart?
When did he first smile? First speak word? Sit up, Crawl, walk, ….
Routine care
When was his last check up? How was his health at that time?
Immunization – Are his immunizations up to date? Do you have vaccination card with you?
I am glad to hear that you are taking good care of your child.
(not taken) May I know why it is so? Mrs.....As a concerned physician I must inform you that
vaccine can protect child from many illness. So I strongly recommend you to complete his
vaccination as soon as possible. (And this kind of vaccines are given free of charge by federal
government health program.) if financial reason Would you like to tell me anything else, Mrs.______?
All right, Mr. Smith,_____ thank you so much for you kind co-operation.
Now let me tell you what I think so far. First of all let me summarize.
As you told me that he has……is that ok?
According to the information I got from you, I am considering possibilities like...But to confirm diagnosis,
I need to examine him/her and run some tests like.... For that I want you to bring your child to the hospital
At that time I will explain you in details and we will also discuss about treatment options? ok?
Have you understand what we discuss today?
Do you have any questions? If no- If you have any question later on, you can call me at any time.
Ok, then, Mrs......It was nice to meet. . Bye. Take care.
** Dr. Dharmesh Mehta had contributed actively in making this proforma.
