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History Taking

Introduction • Introduce yourself and get consent e.g. “Hello my name is X and

I’m a medical student, do you mind if I ask you some questions?”

Patient Identity Name

• Gender

• Age

• Occupation

Presenting

Complaint (PC)

Symptoms and duration
History of

Presenting

Complaint

(HPC)

• Symptoms in detail

• Associated symptoms relevant to PC

• SOCRATES if applicable (see glossary)

• Previous episodes of similar symptoms?

Past Medical

History (PMHx)

• Ongoing medical problems

• Previous illnesses and operations

• MJTHREADS

Drug History

(DHx)

• Medication

• Allergies

• Over-the-counter meds

Family

History (FHx)

• Illness running in the family

• Parents/siblings healthy?

Social

History (SHx)

• Living circumstances

• Activities of daily living

• Smoking, Alcohol

• Pets, Children, Foreign travel

Systems

Enquiry (SE)

• General: Appetite and weight loss

• CVS: Pain, Orthopnoea, PND, palpitations

• Resp: SOB, cough, wheeze, sputum

• GI: N&V, constipation, diarrhoea

• GU: Frequency, urgency, burning, stinging

• Neuro: Fits, faints, funny turns, headaches, visual disturbance.

• Musculoskeletal: Pain/stiffness in joints

Closure Thank the patient
Presentation/

Documentation

• Chronological order

• Concise summary