| 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 |
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History Taking |
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