Taking a Medical History

Basic’s: Allow the patient to talk. Do not interrupt. When patient is finished then ask open ended type questions. Always ask: Is there anything else?

There are many methods and guides used for history taking and as time goes by you will develop your own style. Below are examples of a Medical History:

Classical Medical History

1. Chief Complaint: chronological narrative of problem.
   1. onset
   2. quality
   3. severity
   4. timing (duration, frequency)
   5. what makes worse/better
   6. associated manifestations

2. Past Medical History
   1. general state of health
   2. childhood illnesses
   3. immunizations
   4. adult illnesses
   5. psychiatric illnesses
   6. surgeries
   7. injuries
   8. hospitalizations
   9. ALLERGIES

3. Current Medications

4. Diet

5. Sleep Pattern

6. Habits
   1. smoking
   2. dipping
   3. ETOH intake

7. Family History
   1. HTN
   2. TB
   3. HA
   4. Stroke
   5. heart disease
   6. diabetes
   7. mental illness

8. Psychosocial History
   1. life style, home situation, significant others
   2. school
   3. job
   4. financial
   5. recreation

9. Review of Systems
   1. General
      1. usual weight
      2. weight change
      3. weakness, fatigue, fever
   2. Skin
      1. rashes
      2. lumps
      3. itching
      4. dryness
      5. color changes
      6. hair and nails
   3. Head
      1. HA
      2. head injury
   4. Eyes
      1. vision
      2. corrective lens use; type
      3. last eye exam
      4. pain
      5. redness
      6. tearing
      7. double vision
   5. Ears
      1. hearing
      2. tinnitus
      3. vertigo
      4. pain, earache
      5. infection
      6. discharge
   6. Nose & Sinuses
      1. frequent colds, nasal stuffiness
      2. hay fever, atopy
      3. nosebleeds
      4. sinus trouble
   7. Mouth & Throat
      1. teeth and gums
      2. last dental exam
      3. sore tongue
      4. frequent sore throat
      5. hoarseness
   8. Neck
      1. lumps in neck
      2. pain
   9. Breasts
      1. lumps
      2. nipple discharge
      3. pain
      4. self-exam
   10. Respiratory
       1. cough
       2. sputum (color, quantity)
       3. hemoptysis
       4. wheezing
       5. asthma
       6. bronchitis
       7. pneumonia
       8. TB, last PPD
       9. pleurisy
       10. last CXR
   11. Cardiac
       1. heart trouble
       2. HTN
       3. rheumatic fever
       4. heart murmurs
       5. dyspnea/orthopnea
       6. edema
       7. chest pain/palpitations
       8. last EKG
   12. Gastrointestinal
       1. trouble swallowing
       2. heartburn
       3. appetite
       4. nausea
       5. vomiting
       6. vomiting blood
       7. indigestion
       8. frequency of BM’s, last BM, change in habit
       9. rectal bleeding or tarry stools
       10. constipation
       11. diarrhea
       12. abdominal pain
       13. food intolerance
       14. excessive belching or farting
       15. hemorrhoids
       16. jaundice, liver or gall bladder trouble, hepatitis
   13. Urinary
       1. frequency of urination
       2. polyuria
       3. nocturia
       4. dysuria
       5. hematuria
       6. urgency, hesitancy, incontinence
       7. urinary infections and STD’s
       8. stones (renal calculi)
   14. Genito-reproductive
       1. MALE
          1. discharge from or sores on penis
          2. STD hx and treatment, Last HIV test
          3. hernias
          4. testicular pain or masses
          5. frequency of intercourse, libido, difficulties
       2. FEMALE
          1. 1st menarche, regularity, frequency
          2. flow duration, amount
          3. bleeding between periods or after intercourse
          4. last PAP, results
          5. number of pregnancies, deliveries, abortions (spontaneous & induced)
          6. STD’s hx and treatments, Last HIV test
   15. Musculoskeletal
       1. joint pain/stiffness, arthritis, backache.
          (describe location and swelling, redness, pain, weakness, ROM)
       2. past injuries, treatments
   16. Neurologic
       1. fainting, blackouts, seizures, paralysis, weakness, numbness, tingling, tremors, memory
   17. Psychiatric
       1. mood, affect
       2. nervousness, tension, depression
       3. past care
   18. Endocrine
       1. thyroid trouble
       2. heat or cold intolerance
       3. excessive sweating, thirst, hunger, urination
       4. diabetes
   19. Hematologic
       1. anemia
       2. ease of bruising, bleeding
       3. past transfusions and any reactions

ANOTHER FASTER WAY TO TAKE A MEDICAL HISTORY IS BY USING THE KEY WORD "SAMPLE PQRST"

S: Symptoms
A: Allergies
M: Medicine taken
P: Past history of similar events
L: Last meal
E: Events leading up to illness or injury

P: Provocation/Position - what brought symptoms on, where is pain located.
Q: Quality - sharp, dull, crushing etc...
R: Radiation - does pain travel
S: Severity/Symptoms Associated with - on scale of 1 to 10, what other symptoms occur
T: Timing/Triggers - occasional, constant, intermittent, only when I do this. (activities, food)

Hospital Corpsman Sickcall Screeners Handbook

Naval Hospital, Great Lakes

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