Period, Question Mark, Exclamation Point - Punctuation

AMA Manual of Style - Stacy L. Christiansen, Cheryl Iverson 2020

Period, Question Mark, Exclamation Point

. . . after journeying through the world of punctuation, and seeing what it can do, I am all the more convinced that we should fight like tigers to preserve our punctuation and we should start now.

Lynne Truss1

The popular image of the copy editor is of someone who favors rigid consistency. I don’t usually think of myself that way. But, when pressed, I do find that I have strong views about commas.

Mary Norris2

8.1 Period, Question Mark, Exclamation Point.

Periods, question marks, and exclamation points are the 3 end-of-sentence punctuation marks.

8.1.1 Period.

Periods are the most common end-of-sentence punctuation mark. Use a period at the end of a declarative or imperative sentence and at the end of each table footnote and each figure legend or caption (but not at the end of figure or table titles).

Advances in medical technology have saved many lives.

Always listen carefully.

Indirect questions almost always take a period.

She wondered why the peer review of her manuscript was taking so long.

He wondered why there were no illustrations in the article.

See 8.1.2, Punctuation, Period, Question Mark, Exclamation Point, Question Mark, for advice on rhetorical questions and questions within unspoken dialogue. Placement.

The period precedes ending quotation marks and reference citations.

The child is rated in 7 areas, such as “accepts responsibility” and “interacts appropriately with peers.”

We followed the methods of Wilkes et al.5

The period follows a closing apostrophe:

The intervention group’s scores were better than previous patients’.

If a complete sentence is enclosed in parentheses or brackets, the period precedes the closing parenthesis or bracket.

The serial comma can arouse strong feelings. (The serial comma is the one before the final and in a series of 3 or more items.)

However, see, Punctuation Marks With Parentheses, for examples where the punctuated statement is part of a sentence. Lists.

Use a period after the arabic numeral when enumerating paragraphed items.

The completed authorship form required by the journal included the following sections:

1.Authorship responsibility, criteria, and contributions

2.Confirmation of reporting conflicts of interest and funding

3.Acknowledgment statement

Lists may be run into the text or set off by numbers or bullets (see 18.5, Numbers and Percentages, Enumerations). However they appear, the question of end punctuation arises. Some simple guidelines:

■If the list consists of sentence fragments, use no end punctuation.

■If each listed item consists of 1 or more complete sentences, use end punctuation (eg, period or question mark) at the end of each sentence.

■If the list contains both (ie, sentence fragments and complete sentences), attempt to make all items parallel so that they may all be treated similarly.

The bulleted list below contains a mix of incomplete (first 2 bullets) and complete (last bullet) sentences.

Character and quality of pain were described as follows:

■Diffuse or multifocal, often waxes and wanes, and is frequently migratory

■Often accompanied by dysesthesia or paresthesia, described as “more neuropathic”

■Patients may note discomfort when they are touched or when wearing tight clothing

Make these consistent, as follows:

Character and quality of pain were described as follows:

■Diffuse or multifocal, often waxes and wanes, frequently migratory

■Often accompanied by dysesthesia or paresthesia, described as “more neuropathic”

■Producing discomfort when touched or when tight clothing is worn

If these items are all incomplete sentences or phrases, as those in the revised version are, then the decision about end punctuation is made simpler. However, although the items in the list, as incomplete sentences, do not require end punctuation, the final item would take a period if the items were treated as if they were in a single sentence:

Character and quality of pain were described as follows:

■diffuse or multifocal, often waxes and wanes, frequently migratory;

■often accompanied by dysesthesia or paresthesia, described as “more neuropathic”; and

■producing discomfort when touched or when tight clothing is worn.

These guidelines also apply to items in a table, box, or figure. They apply to items preceded by numbers or bullets and items that stand alone (see 18.5, Numbers and Percentages, Enumerations, for guidance on handling punctuation at the ends of items in bulleted or numbered enumerations and the Enumerations section in 8.2.2, Semicolon, for examples of ways to handle enumerations that are run into the text). Decimals.

Use the period as a decimal indicator (see 18.7.1, Numbers and Percentages, Forms of Numbers, Decimals).

r = 0.75

.32 caliber


P < .05 When Not to Use a Period.

The JAMA Network journals do not use periods with honorifics (courtesy titles), scientific terms, or abbreviations (eg, St, Dr, Blvd) (exceptions: No. for “number” and St. when it is part of a person’s surname, although no period is used with St or Ste in a city name, eg, St Louis, Missouri, or Sault Ste Marie, Michigan) (see 2.2, Author Bylines and End-of-Text Signatures; 3.12.8, References to Books, Publishers; and 13.0, Abbreviations).

Dr Bauchner


Howard Bauchner, MD

Stacy L. Christiansen, MA

Howard C. Bauchner, MD

Ms Christiansen

E coli

Prof Hinders

St John’s wort




HMR Publishing Co


8.1.2 Question Mark.

The primary use of the question mark is to end interrogative sentences.

When did he go into private practice?

Is it time to make mind-body approaches available for chronic low back pain?

Rhetorical questions posed as direct questions usually take a question mark.

Are you serious?

Questions within unspoken dialogue also usually take a question mark.

Why did I bother to attend this conference? she wondered. In Dates.

Use the question mark to show doubt about specific dates.

Hippocrates (460?-375 BCE) is often referred to as the Father of Medicine. Placement.

When the question mark is part of the quoted or parenthetical material, place the question mark inside the end quotation mark (see 8.6.5, Quotation Marks, Placement), the closing parenthesis, or the end bracket.

The patient asked her physician of 25 years, “Why are you retiring, Doctor?”

The chapter on interpretation asks the question “Can I be wrong?”

The mandate for health care reform (can we agree on this?) will change practice as we know it.

In declarative sentences that contain a question, place the question mark at the end of the interrogative statement.

The patient asked, “What is ’average’ pain?”

The investigators asked the question “Have you ever injected drugs?” of every study participant.

Similarly, colons should not appear between the title and the subtitle when other punctuation follows the title.

How Well Is the Affordable Care Act Doing? Reasons for Optimism

Note: The question mark, like the exclamation point (see, Punctuation, Period, Question Mark, Exclamation Point, Exclamation Point, Placement), is never combined with another question mark, exclamation point, period, semicolon, colon, or comma; thus, the need for a comma is obviated in the example below:

The first section of the book, “What Medical Advances Made Open Heart Surgery Possible?” is certain to interest medical historians.

This situation is sometimes referred to as “dueling punctuation marks,” and in this duel, the stronger mark wins.

An indirect question should not end with a question mark (see 8.1.1, Period, Question Mark, Exclamation Point, Period).

She wondered why the article contained no illustrations.

8.1.3 Exclamation Point.

Exclamation points indicate emotion, an outcry, or a forceful comment. Avoid their use except in direct quotations and in rare and special circumstances. They are not appropriate in scientific manuscripts and are more common in less formal articles, such as blog posts and informal essays, where added emphasis may be appropriate. If they are used, do not repeat the punctuation mark for emphasis.


Although it may be referred to as the gold standard, nothing is perfect!

I had almost given up hope of his recovery. He was terribly sick! Placement.

When it completes the emphasized material, the exclamation point goes inside the end quotation mark, parenthesis, or bracket. (The exclamation point, like the question mark [see, Period, Question Mark, Exclamation Point, Question Mark, Placement], is never combined with another exclamation point, question mark, period, semicolon, colon, or comma; thus, there is no comma in the first example below.)

“Let the reader beware!” the editor warned.

The frightened child cried, “I don’t want my tonsils taken out!” Factorial.

In mathematical expressions, the exclamation point is used to indicate a factorial (see 20.6, Commonly Used Symbols).