A case-taking proforma you can use tomorrow

Why a template beats a good memory

You know more Materia Medica than you need for a routine case. What you probably do not have yet is a process — and without one, every consultation is an improvisation, and improvisations are unevenly good.

A fixed record does three things a good memory cannot. It stops you forgetting the thermal state at six o'clock on a Friday. It makes your cases comparable to each other, which is the only way you learn from your own practice. And it produces a record that is still usable at the follow-up, when you will remember far less than you expect.

The order below matters at least as much as the headings.

Before the patient speaks

Decide two things once, in writing, and then stop re-deciding them:

How long a first consultation takes. For a chronic case, 45 to 60 minutes. Booking chronic cases into fifteen-minute slots is the single fastest way to produce bad case records, and no amount of skill compensates for it.

What you record every single time, regardless of the complaint. That is the proforma. Its value comes precisely from being unconditional.

The record

1. Identification and context

Name, age, sex, occupation, marital and family situation, who referred them. Occupation is not administrative — it is often where the maintaining cause lives.

2. The complaint, in the patient's words

Verbatim. Not your translation into clinical language.

Then, for each complaint: location, sensation, modality, concomitant, duration and progression. These five are the classical anatomy of a complete symptom, and a symptom missing its modality is nearly useless for differentiation.

Do not interrupt for the first several minutes. What patients volunteer first, and the words they choose for it, is information you cannot recover later by questioning. Let them run out on their own.

3. Chronology

A dated timeline of the illness, and of the significant illnesses before it.

This is the section students skip and practitioners come to rely on. Without it you cannot recognise a return of old symptoms at the follow-up, which is the most checkable indicator you have — see the direction of cure.

Include: when it began, what was happening in their life at that time, what has changed since, what treatments were tried and what they did.

4. The exciting and maintaining causes

Exciting — what started it. A grief, a fright, a soaking, a suppressed discharge, an injury. Often your single best rubric.

Maintaining — what keeps it going. Shift work, an ongoing conflict, a posture, a stimulant load, an exposure. No potency removes this; you address it directly or the case relapses indefinitely. This is Organon §5 and it is the most frequently skipped question in the whole record.

5. Generals

The section that decides most cases, and the section most often thin.

• Thermal: does the patient feel the cold or the heat more than those around them?
• Appetite, thirst, desires and aversions — and note that a craving and an aversion are different symptoms, not two ways of saying the same thing.
• Sleep: hours, position, dreams if striking, and how they wake.
• Perspiration: where, when, odour, whether it relieves.
• Stool and urine.
• Menstrual and obstetric history where applicable.
• Time modality: what time of day is worst.
• Position, motion, open air, weather, seasons.

6. Mentals — demonstrated, not claimed

The distinction is the whole of it. "I am a calm person" is a claim. Twisting a handkerchief throughout while describing a bereavement is a demonstration.

Record: mood and its direction, fears, response to consolation, anger and its form, anxieties and what they attach to, and how the illness has changed the person.

Response to consolation deserves its own line. It separates several major remedies and takes one question: "What happens when someone tries to comfort you?"

7. Family and personal history

Family illnesses. Personal history: significant illness, surgery, vaccination reactions if striking, current medication and supplements. Medication matters twice over — it can produce symptoms you might otherwise read as peculiar, and it may be maintaining the state.

8. Observation

Manner, posture, dress, how they sit, what they do with their hands, how they respond when asked about difficult material, whether they contradict themselves, whether they are accompanied and how they behave with that person.

This is data, and it is the part that never appears on any form. Write it down deliberately or you will lose it.

9. Examination and investigations

General and systemic examination as indicated. Existing reports. What needs investigating, and whether it needs investigating before you prescribe.

10. Analysis — written, and away from the patient

Ranked list of symptoms with your reasoning. Rubrics selected, with the source. Differential considered and, importantly, why the runners-up were rejected — that line is what makes the case teach you something later.

Then: prescription, potency, repetition, what you have told the patient, and what you expect to change and by when.

Two rules about using it

Analyse away from the patient. Early on, avoid prescribing in the room. Say you will review the case and come back to them. It is normal, it is defensible, and it prevents the commonest beginner error — reaching for the remedy that occurred to you in minute three and then unconsciously collecting evidence for it.

Write the prediction. "What I expect to change, and by when." Fifteen seconds. It is the line that turns a follow-up from an impression into a test, and it will teach you more in ten cases than fifty cases of unstructured review.

Then practise the thing itself

A proforma is a scaffold; the skill is in using it fluently while a real person is talking. That is a separate thing to practise, and it is much easier to practise on a simulated patient than on someone who came for help — you can stall, backtrack and get it wrong at no cost. The case studies are written for that, and there is a broader structure in your first ten patients.