Socio-Demographic details:

______ years (Age) old ________(sex) Patient _____________ (Name), ______ (Religion) residing at ___________ (detailed address), a native of ___________  (mention from where patient has migrated or come from), ___________ (Marital status), educated up to _______  (Education) working as a ____________(Occupation) belonging to socio-economic class _________ (Socio-economic class) was admitted in the hospital on________  (Date of Admission)/came to OPD.

Informant: 

Mention whether self or a family member (If family member, mention the relation with the patient)

Chief  Complaints: 

• Mention the chief complaints with which the patient presented - origin, duration, progress (ODP) and associated events

In case the patient has come to collect medications, and the patient does 

not have any complaints, mention accordingly.

• Any treatment taken for the current symptoms. Mention all the relevant details.

Present History: 

• Ask for symptoms of

1. Fever

2. Cough

3. Chest pain

4. Breathlessness

5. Haemoptysis

6. Weight loss

7. Loss of appetite

8. If extrapulmonary tuberculosis is suspected, then ask for organ specific symptoms

• For the presenting complaints, ask 

1. If the patient has taken treatment for these complaints. 

2. If the patient has taken treatment, from whom was the treatment taken and the duration of treatment taken. 

• In a known case of TB, ask

1. If the patient knows what type of TB he or she has?

2. What were the presenting symptoms at the time of diagnosis? When did symptoms start?

3. What investigations were done and results of investigations?

4. When was the patient diagnosed with TB?

5. When did the patient start treatment? (time taken to start treatment after the patient noticed his symptoms)

6.  Where is the patient taking treatment? Public sector or private sector.

7. What medications is he taking? Ask patient to show the medications he is taking?

8.  If patient does not know the names or does not show the tablets, try to find out whether oral or injectable medications are being consumed. For how long has the patient been told that he would need to take medications.

9. Is he taking his medications as advised?  Ask how many tablets are consumed in a day and the time when they are consumed. 

10. Does the patient take medications on his own or is there a family member who reminds them/or takes out the medicines and gives them to consume.

11. If the patient was initiated on treatment, but has stopped the medications, reasons for discontinuation. 

• Symptoms suggestive of complications like

  1. 1. Haemoptysis

     2. Breathlessness

     3. Chest pain

     4. Wheezing sound

Past History: 

1. Did the patient have any similar complaints in the past?

2. Did the  patient have  any major illness in the past?

3. Did the patient have  any surgery in the past?

4. Did the patient ever get hospitalized?

5. Does the patient take any medications on a regular basis?

6. Did the patient have tuberculosis anytime in the past? If yes, ask

   1. 1. Time of illness (how many years back he was diagnosed).

      2. Type of TB - pulmonary or extrapulmonary.

      3. Was there any history of hospitalization due to TB.

      4. Whether the patient had any complications or side-effects of drugs.

      5. Whether treatment was taken and duration of treatment taken.

      6. Whether treatment was completed and patient certified as cured or treatment completed by the doctor.

7. Is the patient a known diabetic? If yes, ask

   1. 1. How many years back was diagnosed.

      2. If treatment is being taken.

      3. If diabetes is under control or not.

8. Is the patient a known case of HIV-AIDS or any immuno-compromised conditions? If yes,

   1. 1. When was the patient diagnosed?

      2. Is the patient on treatment and since when?

9. Does the patient have any renal diseases? If yes,

   1. 1. When was the patient diagnosed?

      2. Is the patient on treatment and since when?

 Personal History:

1. History of addiction - History of consumption of tobacco, alcohol or drug abuse, with details

2. History of allergies 

3. History of adverse drug reactions

4. History of sexual exposure - (In HIV sero-positives, TB is very common, so it is must to ask in any suspected or confirmed TB patient)

5. Bladder/ bowel complaints

6. Sleep 

7. Appetite 

8. Physical exercise 

Family History:

1. 1. Is there any family member who in the past or currently has tuberculosis.

   2. Is there any family member having diabetes or HIV. (having diabetes or HIV makes them vulnerable)

   3. Find out if they know anyone who has tuberculosis and with whom they regularly come in contact(any friend, relative, colleague)

Menstrual History: 

Age of menarche

Date of last menstrual period 

(Important to rule out pregnancy, since certain drugs are contraindicated in pregnancy. In case patient is drug resistant TB, patient may be advised MTP if less than 20 weeks or if more than 20 weeks, anti-TB regimen may need to be modified).

Past Menstrual Cycle: Duration ______________, Regularity _______________________, Pain during menses __________________ , 

Flow - less/moderate/heavy

Family Planning: 

In female patients ask for the contraceptive method being used.

(Efficacy of Oral Contraceptive Pills is reduced in patients taking anti-tuberculosis drugs, and therefore other contraceptive methods should be used.)

Obstetric History: 

Gravida _____ Para ______Abortion _______Live birth _______ Stillbirth ________.

In pregnant women, ask additional questions pertinent to Antenatal care, the past obstetric history details like the birth history, details of delivery and post-natal care as you would elicit in an ANC case.

Immunization History: 

• In case of children, do ask and check for BCG vaccination scar.

• In adults, ask about Covid-19 vaccination - Name of vaccine received, Number of doses received and date of last dose taken.

Socioeconomic History: 

Details regarding the following should be obtained in history.

• No of person/s living in family and age and sex of family members and their relationship.

• Make a special note of children below 6 years of age, adult family members with diabetes or HIV.

• No. of earning family members and total income.

• Find out who is the head of the family and their details of educational and occupation.

• Calculate socio-economic class using BG Prasad Classification or Modified Kuppuswamy Classification.

Summarise the elicited information by drawing the family tree. State the type of family, mentioning any young children or family members with the HIV or Diabetes and socio-economic class using either B.G. Prasad or Modified Kuppuswamy classification.

Environmental history:

• Lives in Urban slum / Urban Non slum/  Rural

• Housing: Type of house i.e. kaccha / pukka /semi pukka, area of house, etc.

• Overcrowding - State the number of rooms/floor space area of the house in which the patient lives, and state whether overcrowding is present.

•  Lighting & Ventilation - Number of doors and windows. Whether the windows are kept open/closed. Is cross-ventilation present. Is there adequate natural light in the house?

Social Cultural Practices:

Cultural values/ Customs/Habits/ Beliefs/ Attitudes / Stress (Home/ Workplace)/ Health services in community/  

Dietary History: 

Take dietary assessment using a 24 hour recall method. Analyse diet to check caloric and protein intake and summarise as follows.

________(Patient name) consumes _______________(vegetarian /non-vegetarian food) food and eats ____ meals per day (no. of meals). Total caloric intake is _____ kcals and _____ gms of proteins is being consumed.

Diet is deficit /excess by ____ kcals and _____gms of proteins.

General examination:

Built_____________________  Weight in  ___________kg and height of ____________ cms and BMI is _____ kg/m sq.

Pulse rate is  ____________ per min.

BP is ______ mm of Hg in supine position measured in the left arm. 

Respiratory Rate is __________ per min.

Signs / No signs  of pallor, icterus, cyanosis, clubbing, lymphadenopathy, oedema.

Systemic Examination:

Respiratory system:

Cardiovascular system:

Alimentary system:

Central Nervous system

Case Summary: