Health Care
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Introduction
Functional Inquiry This series of symptom related questions is used to elicit new information and obtain further details about the presenting problem. The process of asking these questions is flexible. Open-ended questions should be used to explore a positive response to a closed question. Before you begin, tell the patient that you will be asking him/her a series of questions, many of which may seem unrelated to the reason s/he came to see the doctor. Explain that the purpose of asking these questions is to give a fuller picture of the patient’s overall health and ensure that nothing is missed.
General How is your energy level? Are you sleeping well? Any changes in appetite or weight? Do you have fever/night sweats/shaking? Do you have any rashes/bruising? Have you noticed any changes in your skin colour (pale, yellow, orange, blue, tanned)? Have you experienced any flushing?
Cardiovascular Do you have any pain or discomfort in your chest? Are you short of breath during physical activity/when lying down – does it wake you at night? Do you sometimes get a fluttering feeling in your chest? Do you have any swelling of your ankles? Do you get pain in the calves of your legs when you walk?
Respi ratory Do you have pain in your chest when you breathe? Have you any shortness of breath, wheezing? Do you have a cough? Do you cough up anything – mucous, blood (clear, frothy, pink, green, yellow, blood stained)? Have you had a cold recently?
GastroIntestinal Do you have discomfort when you eat, difficulty swallowing? Do you have indigestion/heartburn? Do you have pain in your stomach? Any bloating, gas? Have you had any nausea or vomiting. What is the vomit – colour, food, acid, blood? Has your skin ever turned yellow? Has there been a change in your bowels – altered frequency or consistency of stools (colour, size, blood or mucous, floating)? What is normal for you?
Genito-Urinary Do you have to pass water often? Any pain? Any change in frequency? At night? Is there any change in your urine – colour, clarity (cloudy), volume or smell? Any blood? Do you ever feel an urgent need to pass water – ever not make it? Ever find you didn’t need to go? Have you ever had a sexually transmitted infection? Do you have pain with sexual activity? Difficulty with orgasm?
Breast history – any breast lumps, nipple discomfort, discharge?
For male – Have you had any hesitancy, dribbling or poor stream? Any discharge – colour, smell, consistency, blood? Do you have any difficulty with erections, ejaculation, impotence? Have you ever had any swelling or pain in your testes?
For female – Any vaginal discharge – colour, smell, consistency? Menstruation: How old where you when your peroids started (menarche)? Age at menopause? Duration of bleeding, how often, how much (number and type of pads)? Do you have any bleeding other than during periods/after menopause? Do you have any pain with your periods? Any flushing/hot flashes? Musculoskeletal Do you have any pain/swelling/stiffness in your muscles/joints/back? Do you have muscle stiffness in the mornings? Are you able to wash and dress without difficulty? Can you climb up and down stairs? Have you noticed any change in your walking?
Ne urological/Psychiatric Do you have headaches? Have you had any fits/faints/loss of consciousness, funny turns? Have you had any dizziness, lightheadedness? Is your vision good? Any double vision, other visual disturbance (wavy lines, halos round lights)? Any hearing problems – deafness, pounding, static, ringing? Do you have any weakness in your body? Any numbness/tingling “pins and needles”? Any shakiness in your hands? Have you noticed any loss of memory/personality change? Do you feel sad, hopeless/have episodes of tearfulness? Do you have any anxiety, insomnia, difficulty concentrating, memory changes?
Haematological Do you have night sweats? Have you noticed any bruising, rashes, red spots? Have you noticed that you have easy &/or prolonged bleeding? Have you ever had a blood transfusion – any reactions? Any swellings in your neck, armpits, groin? Have you noticed or has anyone commented on paleness, yellowness of your skin? Endocrine Do you have fatigue or a general feeling of not being well? Have you noticed any change in how you cope with hot or cold rooms? Have you noticed neck swelling/ tightness? Any increased thirst, hunger? Increased urination? Are you lactating – any breast discharge? Have you had any changes in your skin (rougher, smoother) & hair condition (thicker, thinner, falling out)?
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