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Discipline

: Medicine

Sub Discipline

: Medicine

Document Title

: General Medicine Clerking Note

HISTORY

Chief Complaint

History Of Present Complaint

Systemic Review

General

CVS

Respiratory

Abdomen

Genitourinary

Cns

Ent

Eye

Skin

Musculoskeletal

Others, Specify

Past Medical History

Nil

Diabetes Mellitus

Dyslipidaemia

Hypertension

Ischaemic Heart Disease

Asthma

Tuberculosis

Chronic Obstructive Pulmonary Disease

Stroke

Epilepsy

Chronic Kidney Disease

Cancer

Others, specify

Past Surgical History

Obstetric / Menstrual History

LMP

Menstrual Disorder

Menarche

years old

Menopause

years old

Sexual Dysfunction

Drug History

Other Drug History (shall include supplement)

Allergies And Alert

Social History

Marital Status

Occupation

Smoker

CurrentEx-smoker (stop more than 6 months)Never

Alcohol Consumption

Other Relevant History (Shall Include High Risk Behaviour)

Birth And Neonatal History (Where Relevant)

Immunization (Where Relevant)

Immunisation Method

Dietary History (Where Relevant)

Family History

Occupational History

Functional History

Hand Dominance

RightLeft

Adl Status

Mobility / Ambulation Status

Memory

Depression

GENERAL EXAMINATION

Vital Signs

General Description

Eye

Head And Neck

Cardiovascular

Respiratory System

Abdomen

Genitourinary System

Nervous System

Musculoskeletal

Skin

Others, Specify

PROBLEM LIST

Problem List

DIAGNOSIS

Diagnosis

MANAGEMENT

Orders

Plan

Referral

Outgoing Referrals

Comment

SIGNATURES

Notes Component

HISTORY
GENERAL EXAMINATION
PROBLEM LIST
DIAGNOSIS
MANAGEMENT
SIGNATURES

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