History Taking Flashcards
Step 1
- Obtain history of present illness
Onset: “How long ago did this happen? Did this come on suddenly or gradually?”
Provocation: “What makes your pain/discomfort worse and what makes it better?”
Quality: “Can you describe the feeling?”
Region/radiation: “Where is the pain/discomfort located? Is it moving to any other areas of your body?”
Severity: “Can you tell me on a scale of 0-10 how severe this is?”
T: “What were you doing when this started? Is the pain always there or does it come and go? Has this pain ever happened before?”
Step 2
- Obtain SAMPLE history
Signs and symptoms “can you tell me what’s wrong?”
Allergies “do you have any general allergies or allergies to medications?”
Medications “can you tell me what medications you are currently taking to include over the counter medication, vitamins and/supplements?”
Pertinent past history “do you have any significant past medical history of any chronic illnesses?”
Last intake and output “when was the last time you had anything to eat or drink?”
Events leading to the injury “can you tell me what you were doing before you dialed 911?”
What comes after history taking?
Secondary assessment
