Admission date
Attending date
Name Age Occupation (ex-occupation and current occupation)
Marriage status Living place
Source of information (patient, relative or referring document)
Chief complaint
Present illness
Onset
Duration
Pattern
Severity
Associated symptoms
Aggravated factors
Alleviated factors
Previous same illness
Prior treatment
Course of illness
Past history
Underlying disease
Medication history
Drug used
Drug allergy
Drug abuse
Surgical history
Why (diagnosis)
What (operation)
Where
When
Others related history, such as
HIV
HBV, HCV
Systemic infection risk
Acute diarrhea
Social history
Alcohol drinking
Smoking habit
Health insurance
Social and family status (economic, tradition, education or politics)
Family history
Same illness as the patient (genetics disease)
Others sick members (health status of the family)
Systemic review
Recheck all systems other than mention in present illness