Patient History Taking ( Step by Step )

- Most important part of the visit.
- 70-80% of diagnosis comes from the history.

Components of Patient History
1. Chief Complaint
2. History of the Present Illness
3. Past Medical & Surgical History
4. Family History
5. Social History
6. Allergies & Medications
7. Review of Systems

1. Chief Complaint :
- Why the patient came to you !
- The MAIN REASON for the visit.

2. History of the Present Illness :
- Character
- Location
- Onset
- Better
- Worse
- Associated symptoms
- Duration

3. Past Medical & Surgical History :
- Ask about medicines they take
- Ask about having any operations

4. Family History :
- If parent not alive, what did they die from?
- Ask specifically about diseases such as : TB, Diabetes, Hypertension, Cancer.

5. Social History :
- Occupation
- Marital Status
- Economic status
- Education
- Use of alcohol and tobacco
- Use of drugs
- Sexual History

6. Allergies & Medications :
- Ask about medicine & allergy
- Traditional medicine

7. Review of Systems :
- Start at head and to the feet.
A) HEENT (Head, Eye, Ear, Nose, Throat)
B) Chest
C) Abdomen
D) Genitourinary
E) Skin
F) Musculo-skeletal
G) Neuroligical

Recording of a History !

( Source : MLP, Lecture Handouts)