Jason Wolfe's Patient Clerking Page
A suggested format for clerking patients with all the standard questions you might ever want to ask. I developed this in the months following starting the clinical part of the medical course at LHMC. It might for example be useful for medical students and perhaps 'Nurse Practitioners'.
1. | Introduce myself |
2. | Tell patient what I want to do |
3. | Ask patient if it is alright |
4. | Ask patient if they are comfortable |
1. | Full name |
2. | Age |
3. | Occupation |
4. | Marital Status |
5. | Patient's Address & Telephone |
6. | Next of Kin's Address & Telephone |
7. | GP's name & area |
8. | Hospital consultant |
1. | Could you take me through everything leading up to you coming to hospital. |
2. | Symptoms
|
3. | Others
|
1. | Have you had any other problems requiring treatment or hospitalisation before? |
2. | Are you visiting your GP about any other problems? |
3. | Ask about :-
|
General | |
1. | Weight Loss / Gain |
2. | Appetite / Diet |
3. | Thirst |
4. | Energy / Fatigue |
5. | Lumps |
6. | Fevers |
7. | Itches |
8. | Sleep |
9. | Night Sweats |
Respiratory | |
1. | Cough |
2. | Sputum |
3. | Haemoptysis |
4. | Dyspnoea |
5. | Wheeze |
6. | Chest Pain |
7. | Tachypnoea |
Cardiovascular | |
1. | Exertional dyspnoea |
2. | Paroxysmal Nocturnal Dyspnoea |
3. | Orthopnoea |
4. | Chest Pain |
5. | Palpitations |
6. | Ankle oedema |
7. | Intermittent Claudication |
8. | Headaches |
9. | Rheumatic Fever / Chorea |
Gastrointestinal |
|
Upper Alimentary Tract : | |
1. | Abdominal Pain |
2. | Appetite |
3. | Vomiting / Nausea |
4. | Vomit / Haematemesis |
5. | Belching / Flatulence |
6. | Water Brash |
7. | Heartburn |
8. | Indigestion |
9. | Swallowing / Dysphagia |
Lower Abdominal Tract : | |
1. | Diarrhoea |
2. | Constipation |
3. | Stools (Steatorrhoea, Blood, Slime, Consistency, Colour, Flushing) |
4. | Pain |
5. | Frequency / Bowel Habit |
6. | Tenesmus / Urgency |
Liver & Gallbladder : | |
1. | Jaundice |
2. | Colour of Urine and Faeces |
3. | Itching Skin |
4. | Pain |
Genito-Urinary System |
|
Urinary : | |
1. | Loin Pain / Dysuria |
2. | Oedema |
3. | Incontinence |
4. | Haematuria |
5. | Nocturia |
6. | Frequency |
7. | Polyuria / Oliguria |
8. | Hesitancy |
9. | Terminal Dribbling |
Genital : | |
1. | Vaginal / Urethral Discharge |
2. | Menses (Frequency, Regularity, Heavy or Light, Duration, Pain) |
3. | Perineal Pain / Swelling / Ulceration |
4. | Pregnancies (Gravida / Para) |
5. | Menarche / Menopause |
6. | Infertility |
7. | Sex Life / Dyspareunia |
Neurological | |
1. | Sight |
2. | Hearing |
3. | Taste |
4. | Touch |
5. | Smell |
6. | Epilepsy / Seizures |
7. | Faints / Blackouts |
8. | Headaches |
9. | Injuries |
10. | Parasthesia / Sensation |
11. | Motor Weakness / Muscle Twitches |
12. | Nausea / Vomiting |
13. | Paralysis / Stroke |
14. | Balance / Coordination |
15. | Speech |
16. | Higher Mental Function |
17. | Psychiatric Symptoms (Anxiety, Phobias, Obsessive Thoughts, Compulsive Acts) (Depression, Mania, Psychoses) |
Musculo-Skeletal | |
1. | Pain |
2. | Stiffness |
3. | Swelling of Joints |
4. | Functioning of Joints / Mobility |
Skin | |
1. | Rashes |
2. | Itching |
3. | Smell |
4. | Drugs |
5. | Hobbies / Occupation |
6. | Personal Hygiene |
7. | Allergies |
Family History | |
1. | Could you tell me a little about the rest of your family. How well are they? |
2. | Parents |
3. | Siblings |
4. | Children |
5. | Ages |
6. | Diseases |
7. | Causes of Death |
Social and Occupational History | |
1. | Marital status |
2. | Spouse - Health and Job |
3. | Past & Present Jobs |
4. | Housing (Stairs to Climb ?) |
5. | Support (Shopping & Cooking, Home help, Meals on wheels, District Nurse) |
6. | Visitors |
7. | Social Life |
8. | Hobbies / Pets |
9. | What patient can and can't do because of illness |
10. | Diet |
11. | Alcohol / Tobacco / Drugs of Abuse |
1. | Past & Present Drugs |
2. | Allergic Reactions to Drugs |
3. | Other Reactions to Drugs |