History Taking

Greet ike- pattene

Wash your hands
Introduce yourself by giving your name and your role
[My name is . , I am a second year medical student)
Ask about the patient's name and check that it is their preferred
form
[Can I please know your good name?)
o [How would you like me to address you?]
Consent
o (I was asked to talk to you, is that fine by you?]
(Do you mind if I take some notes?]
Confidentiality
Establish initial
[l would like to assure you that everything that happens, would stay between
me, you and my rapport
su ervisin doctor)
Comfort
(If I may ask you, do you feel comfortable in here?]

Use the
patient's own
Ask the patient to describe their problem using an open-ended question words
(What's brought you into hospital today?]
Engage the
patient
Enquire more about the presenting complaint
Generalized symptoms (get specific)
What do you mean by?
Stop and notice
When did it start?
(opening
Sleep patterns
o gambit, verbal
How is it affecting you?
cues, nonverbal
cues and curtain
Pain (SOCRATES)
raisers)
Site
Onset
Remain
Character
Conversational
Radiation
Associated Symptoms
Timing Set professional
Exacerbation boundaries
Severity
Review of Symptoms ferrule on
[Quick review form head to toe]
ump

Past medical history

[Have you been hospitalized before?]
Past surgical history
[Did you have any surgeries before?]
Allergies
[Do you have any known allergies?]
 Regular prescribed drugs
o [Do you take any regular medications?)

Over the counter drugs

[What about over the counter medications?]

Parents
[Tell me more about your parents]
(Do you have any ongoing diseases in the family?]
o Siblings
[What about any siblings?]
Spouse
[Are you married?]
[If yes, do you have any children?]
Grandparents
[Can you tell me about your grandparents? I

Smoking, alcohol, illicit drugs and sexual activity

[l know that the coming questions rnight seem private, but they are really important for me to
Nonjudgmental
body language
ask
Diet and exercise
[How do you describe your diet?]
[Do you exercise?]
Occupation and residence
[May I know, what is your job?]
(Where do you live?]
Nationality
[What is your nationality?]

) HI's
Ideas
[It is clear that you have given this a lot of thought and it would be helpful to hear what you think
might be going on?]
u Concerns
[What is your biggest concern or worry at the moment regarding what brought you here?)
Expectations
[What would ideally need to happen for you to feel today's consultation was a success?]

Summarize
[To recap
Additional remarks
[Is there anything extra you would like to add?]
Thank the patient