History taking Flashcards
1
Q
- Introduce yourself
A
Introduce yourself, identify patient and gain consent to speak with them
Ask for their name and DOB
2
Q
- PCO
A
Patient complains of (they tell you what’s wrong/ what has brought them here today)
3
Q
- History of presenting complaint
A
Site - where is the pain?
Onset - when did the pain start? Constant/ intermittent/ gradual/ sudden
Character - what is the pain like? e.g. sharp/ burning/ tight
Radiation - does the pain radiate/ move anywhere?
Associations - anything associated with the pain e.g. sweating?
Time course - does it follow any time pattern/ how long does it last?
Exacerbating/ relieving factors - does anything make it better or worse?
Severity - how severe is pain on scale of 1-10?
4
Q
- Past medical history
A
Are you fit and well Have you had any operations? Do you take any medications? Have you had any heart trouble? Do you have high blood pressure? Have you had any chest trouble? Do you have any bleeding problems? Do you have any allergies? Are you pregnant? Do you have diabetes/ epilepsy/ asthma? Are they well managed? Have you taken any steroids?
5
Q
- Drug history
A
Do you take any medications?
6
Q
- Family history
A
Family history of certain illnesses?
7
Q
- Social/ dental history
A
Dental habits Amount, frequency of sugar Erosive eating or drinking preferences Smoking: do you smoke? How many per day? Alcohol: do you drink? How many units per week?
