Clinical Templates for MBBS Students

What the Clinical Templates Library Covers

The GeckoMed templates library is organised around the three types of clinical documentation MBBS students encounter during their Phase 3 and Final Year postings.

History Taking Proformas

Structured history taking templates for the major clinical subjects. A well-structured history is the foundation of both ward presentations and MBBS clinical exams. Each proforma in the library follows the standard MBBS history format — presenting complaint, history of presenting illness, past history, family history, personal history, drug history, socioeconomic history, and review of systems — adapted for the specific requirements of each subject.

1. General Medicine History Taking Proforma

Patient DetailsName, age, sex, occupation, address, hospital number, date of admission, date of examination.

Chief ComplaintsList the main complaints in chronological order with duration.

History of Presenting IllnessOnset, duration, progression, aggravating factors, relieving factors, associated symptoms, relevant negatives, treatment taken before admission.

Past HistoryPrevious similar episodes, diabetes mellitus, hypertension, tuberculosis, bronchial asthma, epilepsy, jaundice, cardiac disease, renal disease, surgeries, blood transfusion, hospital admissions.

Drug HistoryCurrent medication, past medication, steroid use, anticoagulant use, drug allergy.

Family HistorySimilar illness in family, diabetes, hypertension, tuberculosis, genetic disorders, deaths in family.

Personal HistoryDiet, appetite, sleep, bowel habits, bladder habits, smoking, alcohol intake, substance use.

Socioeconomic HistoryType of housing, sanitation, water supply, occupation-related exposure, family income group where relevant.

Review of SystemsRespiratory, cardiovascular, gastrointestinal, genitourinary, nervous system, musculoskeletal system.

Provisional DiagnosisBased on history and clinical findings.

2. General Surgery Case History Proforma

Patient DetailsName, age, sex, occupation, address, date of admission, date of examination.

Chief ComplaintsMain surgical complaints with duration.

History of Presenting IllnessPain, swelling, ulcer, lump, vomiting, constipation, bleeding, trauma history, fever, weight loss, discharge, obstruction symptoms.

Pain HistorySite, onset, character, radiation, duration, severity, aggravating factors, relieving factors.

Swelling or Lump HistorySite, duration, onset, progression, pain, reducibility, cough impulse, discharge, ulceration, associated symptoms.

Past Surgical HistoryPrevious operations, anaesthesia history, complications, blood transfusion.

Past Medical HistoryDiabetes, hypertension, tuberculosis, asthma, bleeding disorders, cardiac disease.

Personal HistoryDiet, appetite, bowel habits, bladder habits, addictions.

Examination FormatGeneral examination, vitals, local examination, inspection, palpation, percussion, auscultation where applicable, regional lymph nodes, systemic examination.

Provisional DiagnosisClinical diagnosis with differential diagnosis.

3. Obstetrics History Taking Proforma

Patient DetailsName, age, address, occupation, hospital number, date of admission, date of examination.

Chief ComplaintsPresenting complaints with duration.

Menstrual HistoryAge at menarche, cycle regularity, duration of flow, amount of flow, pain during menstruation, last menstrual period, expected date of delivery.

Obstetric HistoryGravida, para, living children, abortions, deaths, previous pregnancies, mode of delivery, birth weight, antenatal complications, intrapartum complications, postpartum complications.

Present Pregnancy HistoryPeriod of gestation, antenatal visits, immunisation, iron and folic acid intake, calcium intake, fetal movements, bleeding per vaginum, leaking per vaginum, pain abdomen, swelling of feet, headache, blurring of vision, fever, urinary complaints.

Past HistoryHypertension, diabetes, thyroid disease, tuberculosis, epilepsy, cardiac disease, renal disease, surgeries.

Family HistoryTwins, congenital anomalies, diabetes, hypertension, genetic disorders.

Personal HistoryDiet, sleep, bowel habits, bladder habits, addictions.

Examination FormatGeneral examination, vitals, pallor, icterus, edema, breast examination, abdominal examination, fundal height, lie, presentation, position, fetal heart rate, uterine contractions where relevant.

Provisional DiagnosisObstetric score with period of gestation and clinical condition.

4. Gynaecology History Taking Proforma

Patient DetailsName, age, marital status, occupation, address, date of examination.

Chief ComplaintsBleeding, discharge, pain, infertility, mass, urinary complaints, menstrual complaints.

Menstrual HistoryMenarche, cycle length, regularity, duration, flow, dysmenorrhea, intermenstrual bleeding, postcoital bleeding, last menstrual period.

Marital and Sexual HistoryAge at marriage, duration of married life, sexual activity, dyspareunia, contraception use.

Obstetric HistoryGravida, para, abortions, living children, previous deliveries, complications.

Contraceptive HistoryMethod used, duration, side effects, reason for stopping if applicable.

Past HistoryTuberculosis, diabetes, hypertension, thyroid disease, pelvic inflammatory disease, surgeries.

Examination FormatGeneral examination, abdominal examination, local examination, speculum examination, bimanual examination where taught and permitted in the clinical setting.

Provisional DiagnosisClinical diagnosis with likely cause.

5. Paediatrics History Taking Proforma

Patient DetailsName, age, sex, address, informant, reliability of informant, date of examination.

Chief ComplaintsMain complaints with duration.

History of Presenting IllnessFever, cough, breathing difficulty, loose stools, vomiting, seizures, feeding difficulty, altered sensorium, rash, swelling, developmental concerns.

Birth HistoryAntenatal history, natal history, mode of delivery, cry at birth, birth weight, NICU admission, neonatal complications.

Developmental HistoryGross motor, fine motor, language, social milestones.

Immunisation HistoryAs per National Immunization Schedule, missed doses, adverse events.

Nutritional HistoryBreastfeeding, complementary feeding, diet recall, feeding problems, vitamin and mineral supplementation.

Past HistoryPrevious admissions, recurrent infections, seizures, asthma, tuberculosis contact, surgeries.

Family HistoryConsanguinity, sibling deaths, hereditary illness, tuberculosis contact.

Examination FormatGeneral examination, anthropometry, vitals, pallor, icterus, cyanosis, clubbing, lymph nodes, edema, hydration status, systemic examination.

Provisional DiagnosisAge with clinical diagnosis and nutritional or immunisation status where relevant.

Clinical Examination Sheets

Systematic examination checklists for each MBBS clinical subject. These are structured to mirror the sequence expected in MBBS long-case and short-case exams — general examination, vital signs, followed by system-specific examination in the correct order. Examination sheets help students build examination habits during postings that will carry through to their Final Year university practical exams.

1. General Examination Sheet

General ConditionConsciousness, orientation, comfort at rest, build, nourishment.

VitalsPulse, blood pressure, respiratory rate, temperature, oxygen saturation.

General SignsPallor, icterus, cyanosis, clubbing, lymphadenopathy, edema, dehydration.

Anthropometry Where RelevantHeight, weight, BMI, mid-upper arm circumference in children, growth chart plotting.

Systemic Examination PlanCardiovascular system, respiratory system, abdomen, central nervous system.

2. CVS Examination Sheet

InspectionPrecordial bulge, visible pulsations, scars, dilated veins, apex beat visibility.

PalpationApex beat location, character, parasternal heave, thrills.

PercussionCardiac borders where taught.

AuscultationS1, S2, added sounds, murmurs, pericardial rub.

Peripheral SignsPulse character, radio-radial delay, radio-femoral delay, blood pressure in both arms where needed, raised JVP, pedal edema.

3. Respiratory System Examination Sheet

InspectionChest shape, symmetry, respiratory rate, use of accessory muscles, scars, deformity.

PalpationTracheal position, chest expansion, tactile vocal fremitus.

PercussionResonant, dull, stony dull, hyperresonant areas.

AuscultationBreath sounds, added sounds, vocal resonance.

Clinical ImpressionLikely consolidation, pleural effusion, pneumothorax, COPD, bronchial asthma, or other clinical pattern.

4. Abdominal Examination Sheet

InspectionShape, distension, scars, sinuses, visible peristalsis, visible pulsations, umbilicus.

PalpationTenderness, guarding, rigidity, organomegaly, masses, hernial sites.

PercussionLiver span, shifting dullness, fluid thrill where relevant.

AuscultationBowel sounds, bruit.

Additional ExaminationExternal genitalia, hernial orifices, rectal examination where taught and clinically appropriate.

5. CNS Examination Sheet

Higher Mental FunctionsConsciousness, orientation, memory, speech.

Cranial NervesI to XII examination as required.

Motor SystemBulk, tone, power, reflexes, coordination, involuntary movements.

Sensory SystemPain, touch, temperature, vibration, joint position sense.

Cerebellar SignsFinger-nose test, heel-shin test, dysdiadochokinesia, gait.

Signs of Meningeal IrritationNeck stiffness, Kernig sign, Brudzinski sign where relevant.

Case Presentation and SOAP Note Formats

Case presentation templates used for clinical seminars, ward rounds, and OSCE stations. The SOAP (Subjective, Objective, Assessment, Plan) format is increasingly used in clinical teaching under the NMC CBME framework, and MBBS students who learn it during postings are better prepared for structured clinical assessments. The GeckoMed case presentation template walks through a complete SOAP note with field descriptions, a filled example, and notes on common errors.

SOAP Case Presentation Format

S: SubjectiveChief complaints, history of presenting illness, relevant past history, personal history, family history, patient-reported symptoms.

O: ObjectiveVitals, general examination, systemic examination, investigation findings.

A: AssessmentProvisional diagnosis, differential diagnosis, clinical reasoning.

P: PlanInvestigations planned, treatment plan, monitoring plan, referral plan, patient education points.

Forensic Medicine Documentation Templates

Curriculum-aligned templates for documentation studied as part of the Phase 2 Forensic Medicine and Toxicology syllabus. These cover the formats students learn about in FMT — not working clinical documents, but the standard layouts taught in the FMT paper for exam purposes. Topics include medico-legal case documentation, wound description format, and the structure of an injury certificate as taught in Phase 2.

Medico-Legal Case Entry FormatPatient identification details, date and time of examination, brought by whom, consent, history as stated by patient or attendant, examination findings, injury details, samples collected, police intimation details.

Wound Description FormatType of wound, site, size, shape, margins, edges, depth, direction, age of injury, surrounding tissue condition, probable weapon, simple or grievous nature where applicable.

Injury Certificate FormatPatient details, identification marks, history, clinical findings, injury description, opinion, advice, doctor details, signature, date, seal.

Community Medicine Field Templates

Structured formats for Community Medicine fieldwork and posting records, aligned to the Phase 3 Community Medicine syllabus. Covers health survey forms, family study proformas, nutritional assessment formats, and environmental sanitation survey templates as used in rural postings and urban health centre visits.

Family Study ProformaFamily identification details, family type, members, age, sex, education, occupation, income, housing, sanitation, water source, waste disposal, morbidity profile.

Nutritional Assessment FormatDiet history, 24-hour recall, anthropometry, BMI, MUAC, clinical signs of deficiency, dietary advice.

Health Survey FormatDemographic details, immunisation status, maternal and child health details, communicable disease history, non-communicable disease risk factors, health service use.

Environmental Sanitation Survey FormatHousing type, ventilation, overcrowding, water supply, toilet facility, waste disposal, vector breeding sites, kitchen hygiene.

Why Structured Templates Matter in MBBS Clinical Years

Clinical exams reward systematic structure. In MBBS long-case exams, the examiner is assessing not just whether you know the diagnosis, but whether you can present the case in a coherent, structured way. Students who have practised using a history and examination template during postings are faster and more organised under exam conditions.

Posting record books require consistent documentation. Most MBBS colleges require students to maintain a posting record or log book with completed case write-ups. Having a standard template reduces the time spent deciding how to structure each case and ensures all required fields are completed before the record book is submitted for assessment.

Early mistakes in documentation are corrected before they become habits. The most common clinical documentation errors in MBBS — omitting socioeconomic history, skipping the review of systems, not recording vital signs in the correct sequence — become harder to correct the longer they are repeated. Using a structured template from the start of 3rd Year prevents these errors from becoming habitual.

OSCE stations require precise format compliance. As OSCE-format assessments become more common across Indian medical universities under the NMC CBME framework, students who are familiar with standardised clinical documentation formats have a measurable advantage in stations that require written case summaries or structured clinical notes.

When to Use the Clinical Templates Library

Before starting a new clinical posting. Each major posting has different documentation expectations. Downloading and reviewing the relevant history template before the first day of a General Medicine, Surgery, OBG, or Paediatrics posting reduces the adjustment time and lets students focus on clinical learning rather than format.

While preparing for Final Year university practical exams. MBBS final professional exams include a long-case component where students are given 20 to 30 minutes with a patient before presenting to the examiner. Students who have practised structured history taking and case presentation throughout their clinical years perform significantly better in this component than those who try to learn the format in the revision period.

During Forensic Medicine and Community Medicine theory revision. The documentation templates for FMT and Community Medicine are exam-oriented — they help students understand and memorise the structured formats that appear as answer templates in short-answer and long-answer questions.

Related Resources

MBBS Clinical Reference Library Normal lab values and immunization schedules that complement the clinical templates. The normal lab values chart is particularly useful alongside General Medicine and Paediatrics history and examination templates.

Viva Preparation Viva questions that test the same clinical knowledge applied in templates. The OBG viva questions align closely with the OBG history and examination templates.

Medical Topics Library Condition-wise topic pages that provide the clinical context behind the cases students encounter during postings. Reviewing the topic page for hypertension, diabetes mellitus, or preeclampsia before a posting helps students complete history and examination templates more accurately.

MBBS Practical & OSCE Exam Prep Practical exam guides for anatomy and biochemistry practicals. The OSCE preparation content bridges the gap between practical exam skills and the structured documentation templates in this library.

MBBS Notes Subject-wise notes that provide the background knowledge needed to complete clinical templates accurately. Anatomy notes for MBBS 1st year and community medicine notes PDF are the most directly relevant.

Frequently Asked Questions