History Taking COPY

Question 1

Introduction

Answer 1

Identify yourself and the patient fully
Explain reason for consultation and gain consent to proceed

Question 2

History

Answer 2

PRESENTING COMPLAINT
HISTORY OF PRESENTING COMPLAINT
PREVIOUS MEDICAL/SURGICAL HISTORY
MEDICATION HISTORY & ALLERGIES
IMMUNISATION HISTORY
FAMILY HISTORY
SOCIAL HISTORY

Question 3

PRESENTING COMPLAINT

Answer 3

Cause for presentation/most important symptom
Duration of symptom

Question 4

HISTORY OF PRESENTING COMPLAINT

Answer 4

Details of all current symptoms
This may include:
-Site
-Onset
-Character
-Radiation
-Associated symptoms
-Timing (duration, course, pattern)
-Exacerbating/relieving factors
-Severity
-Functional consequences
Ask relevant systematic enquiry questions

Question 5

PREVIOUS MEDICAL/SURGICAL HISTORY

Answer 5

Notable illnesses/surgery/GP managed long term
condition
Notable adverse events/problems during
management of illness (eg problems with
anaesthesia)

Question 6

MEDICATION HISTORY & ALLERGIES

Answer 6

Drugs – name, dose, frequency, route, indication and concordance:
- Prescription medicines – including OCP and HRT
- Over the counter (OTC) medicines
- Complementary or alternative medicines
- ’Recreational’ drugs

Allergies:
- Allergens – Medicine/Other
- Effect
- Other sensitivities/significant adverse or
sensitivities to medicines (i.e. not allergies)

Question 7

IMMUNISATION HISTORY

Answer 7

Immunisations – name and date
- Allergies or side effects

Question 8

FAMILY HISTORY

Answer 8

First degree relatives - parents, siblings and children:
- Age & current health or Age at & cause of death
- Details of notable illness

Question 9

SOCIAL HISTORY

Answer 9

Work circumstances
* Social circumstances
* Household members if relevant
* Driving status
* Physical Activity - time spent active every week
* Diet – typical food eaten in a day
* Smoking – duration & amount
* Alcohol – amount & type
* Recreational drugs
* Hobbies
* Pets
* Overseas travel