Medical History Taking
Specific History Taking Checklists, Templates:
History Taking Techniques
Taking a Medical History the Proper Way
History taking in medicine is the most important aspect of the medical examination. You can retrieve more than 90% of your diagnoses through a good and effective history taking method. I actually used this methods below for all my OSCE exams and licensing examinations, USMLE and MCCQE, and literally destroyed those exams. This is a no fault history taking technique and history taking mnemonics that you can basically never forgot. The below method can cover all your corners and not miss even the littlest details when its 4 am and your on-call. Here we will describe a concise and easy method to take a history.
History Taking Template
Medical History Taking Process:
What is your name ?
What is your age?
What is your occupation?
What is your marital status?
What is the reason that you are here today?
History of Present Illness
History Taking Mnemonics
This can be done through a simple mnemonic, OPQRSSTUVWX, with HITS, ART, NFLD or just through who, what, where, when, why, how, etc…
O – Onset/Course of disease and/or problem – When did this happen? How many times has this happened? How long did it occur each time?
P – Provoke – What causes the problem/symptoms?
P – Point – Can you point to the area of the symptoms? Can you point to the area where it is the worst?
Q – Quality – Can you describe to me the symptoms/pain? What is the quality of the pain, sharp stabbing-like or a dull ache?
R – Radiating – Do the symptoms radiate? Does the pain shoot or transfer to other parts of the body?
S – Setting – Where do the symptoms occur? Work or Home? Where are the symptoms worse, early in the day, or late? When you awake?
S – Severity – How bad are the symptoms? How painful is it? From a scale of 1-10, with 10 being the worse pain you have ever had, where would you rate this?
T – Timing – Are the symptoms constant or intermittent? Does the pain/symptoms fluctuate?
U – Bucket for the rest – Any other symptoms? What else happens when you feel these pains/symptoms? (To pick up any associated symptoms).
V – alleViate – Does anything alleviate the symptoms? Does anything help?
W – Wrong – What do you think is wrong?
X – What are all the treatments and procedures that have been performed in regards to your present symptoms/state?
Past Medical History
(HITS) Surgeries – Hospitalizations – Illnesses – Trauma
Last Meal (if patient might go into surgery soon for the problem)
(ART) – Agent that causes the reaction (e.g. Penicillin), Reaction type (e.g. mild rash, anaphylaxis), and Treatments for the reaction if any (e.g. Epi-Pen)
Medical Alert Bracelet – ask about
(NDFL) Name, Dosage, Frequency, Length of usage
Ask specifically about certain drug families known to cause problems NSAIDS (e.g. for ulcers, kidney issues), steroids, etc..
Herbs and Herbal Medicines – these can interact with many drugs
Traditional Medicines – ask about these, as many people do not believe they are Herbs, etc…
Smoking (e.g. How many packs per day? How many years? Calculate as Pack-Years, where 1 pack-year is 1 cigarette pack per day per year, such that 2 packs smoked per day per year equals 2 Pack-Years for that individual, if done for 10 years, equals 20 Pack-Years, and so on)
Alcohol (e.g. How many drinks of alcohol do you usually have during a week? Always add 2-4 drinks on what they say? Do the CAGE questionnare if worried)
Recreational drugs (e.g. Have you recently had any cocaine? marihuana? heroin?)
Coffee (e.g. How many cups a day?)
Diet (e.g. Home cooked meals? Fast food?)
Lifestyle (e.g. Do you exercise? Drive to work? Walk home?)
May have to draw a pedigree to delineate any type of inheritance traits (e.g. X-linked or autosomal dominant vs. recessive)
Atopy (asthma, allergic rhinitis, eczema)
General Review of Systems
General: How is your general health like?
Any changes in your (seaw) Sleep? Energy level/Fatigue? Appetite? Weight?
Any (cfs) Chills, Fevers, Sweats?
Any Nausea, Vomitting (bilious, feculent, blood), Diarrhea, Malaise?
Any Headaches, Dizziness, Lightheadedness, Fainting spells, Life stresses?
Any Muscle or Joint Pains? Any Pain at all?