The Medical History Guidelines & Components:

Updated 6/2020

Objectives:

1. List the components of the complete health history. (PC, MK) [L1] (B1.06, B2.04, B2.05)
2. Elicit a complete medical history from a standardized patient. (MK, PC, ICS, P) [L1, PsyM]
(B1.06, B2.04, B2.05)
3. Demonstrate the ability to identify pertinent positives and negatives in the health history. (PC,
ICS) [L1] (B1.06, B2.04, B2.05)
4. Improve interviewing skills. (ICS, P) [L1, Aff, Pym] (B1.06, B2.04, B2.05)
5. Incorporate feedback from a standardized patient. (PC, ICS, P) [L3, Aff, PsyM]
(B1.06,B2.04,B2.05)
6. Incorporate feedback from PA faculty regarding interviewing techniques. (PC,ICS,P) [L3,Aff]
(B1.06,B2.04,B2.05)
7. Complete the write-up of the medical history and submit it for evaluation. (MK,PC,ICS) [L2,L3]
(B1.06,B2.04,B2.05)
8. Develop appropriate professional conduct while interacting with patients, medical staff, faculty
and fellow students. (PC,ICS,P) [Aff,PsyM] (B1.06,B2.04,B2.05)
.

General Guidelines- History Write Up

All components of the complete medical history should be included. Provide the date and basic
identifying patient information first. To ensure confidentiality, exclude the person's name and use only
initials.

§ The chief complaint is the reason that the patient is seeking medical care. This may be in the
patient's own words if appropriate (contributes to understanding the problem) and may include the
duration of the problem.

§ The history of present illness should start with some identifying information, then the chief
complaint restated and next the symptomatology using the OLDCARTS format in chronological
order. Pertinent negatives should be included. Finally, supportive, pertinent information from the
R.O.S., past medical history, family history and social history are required. The HPI must be
written in paragraph form, telegraphic style is unacceptable.

§ The past medical history includes childhood and adult illness subheadings. The other headings
are Surgery, Trauma, Immunizations, Transfusions, Current Medications and Allergies. Bullet
format is preferred.

§ Family history is next using either bullet-points or genogram to denote family members. A key
should be included with the genogram. Pertinent negatives follow the genogram/bullet points.
Equally important are trends in family history that are not included on the genogram/bullet points.
 § Following the family history is the social history/personal profile. This should be detailed
including preventive medicine issues, daily and sleep habits, nutrition, marital status/social support
systems, etc. Paragraph form or bullet format is acceptable.

§ The final component of the complete medical history is the review of systems. Positive
findings should be recorded first followed by the negatives. Elaborate on the significant positive
findings. It is not appropriate to state that the system involved is "WNL" or "no
complaints". Report each question you ask the patient.

Take care to place information under the correct heading and to be accurate with spelling.

COMPONENTS OF THE MEDICAL HISTORY

DATE OF EXAM:

IDENTIFYING DATA:
● Patient ● Sex and gender ● Source of information
Initials ● Ethnicity/ race ● Language, if not English
● Date of birth
and age

CHIEF COMPLAINT (C.C.)

· Main problem(s) (or reason for seeking medical attention)
· Use patient's words in quotations, unless unable to do so.

HISTORY OF PRESENT ILLNESS (H.P.I.)

Paragraph I. - Detailed characterization of patient's current problem(s). The patient's usual state of health
may be stated prior to details of HPI. For each problem, indicate:
· Onset
· Location
· Duration
· Character
· Aggravators
· Relievers
· Treatments attempted and their efficacy
· Symptoms associated with the problem
This information should be organized in chronological order. The characterization of the problem won't
necessarily follow the order listed above. Complete the system review here in H.P.I. when CC involves
that system. Include pertinent positives as well as pertinent negatives.

Paragraph II. - Pertinent other data, including information from PMH, Personal Profile, ROS, Fam. Hx.,
and results of any evaluation (e.g., lab tests, radiologic examinations, consultant's reports, etc.) performed
prior to the current hospitalization. Deciding what to include here requires judgement based on what the
current complaint is and what items from the history may be germane.

PAST MEDICAL HISTORY (PMH)

● Medical- Indicate date/year of diagnosis, treatment, current status, and nonsurgical

hospitalizations
○ Significant childhood Illness
○ Adult Illnesses - note presence or absence of significant or chronic diseases, such
as diabetes, hypertension, cancer, heart disease, pulmonary disease, hepatitis,
ulcers (including HPI illness(es)).
● Surgery- indicate operation, diagnosis, date, hospital, sequelae. List in chronological
order.
● Trauma- type, surgery if needed, date, sequelae (may include this information under
"Surgery" if indicated)
● Immunizations- depending on age, occupation and health status, may include MMR,
OPV, DTP or Td, Hepatitis B, Hepatitis A, influenza, varicella and pneumococcal. See
guidelines that follow.
● Transfusions- include dates

ALLERGIES: Allergies/adverse reactions and what occurred.

MEDICATIONS: Active current meds

FAMILY HISTORY (Fam. Hx)

Use bullet points or a genogram. List significant illnesses in this section. Indicate ages and state of health
of parents, siblings, children. For other family members, report significant trends in the family in the
paragraph that follows.

Include a key for the symbols if you are using a genogram. Standard symbols:
Square = male
Circle = female
Triangle = unborn child
/ = deceased
= marital relationship when joining a square and circle directly, siblings when
joining vertical lines descending to other individuals
----- = divorced
 Use an arrow to indicate the patient.

Include a narrative of pertinent negatives that follows the family history. Specifically mention diabetes,
hypertension, lipid disorders, CAD, cancer, alcohol dependence/abuse, mental illness (including
depression), unusual or early deaths, or known genetic illnesses (e.g., sickle cell).

PATIENT PROFILE/SOCIAL HISTORY (P.P./Soc. Hx.) “Now I’d like to ask you some questions about
what you do to stay healthy”

· Born and Raised · Tobacco

· Educational & Occupational Status · Alcohol

· Marital History/Social Support · Other drug use

· Sexuality · Diet/Nutrition

· Children · Exercise

· Military History · Seatbelts

· Hobbies/Interests · Helmets

· Travel History · Stress

· Religion/spiritual beliefs · Violence/safety

· Home health care/other health · Sun exposure/ Sunscreen use

beliefs

REVIEW OF SYSTEMS (R.O.S.)

Indicate positives and negatives, explaining details of significant positives. May use "See HPI". Positive
findings should be listed first, and bolded. Do not use terms such as "unremarkable" or "normal".

General: fever, chills, sweats, unexplained weight loss or gain, fatigue, sleep problems.
Integumentary: Rashes, lesions, pruritus, hair or nail changes.

HEENT:
Head: Headache (HA), trauma, masses.
Eyes: acuity, diplopia, blurring, trauma, pain, discharge, tearing, scotomata; if glasses, date of last exam,
glaucoma, cataracts, photophobia.
Ears: changes in hearing, tinnitus, pain, discharge.
Nose: discharge (rhinorrhea or post-nasal drip), trauma, blockage, epistaxis, hx. of sinusitis.
Throat/Mouth: dysphagia, odynophagia, hoarseness, tongue changes, difficulty chewing,
dental caries, dentures, last dental exam.

Neck: lumps, swollen glands, pain

Respiratory: cough, sputum (color, quantity), hemoptysis, dyspnea (quantitate), DOE, wheezing, chest
pain; if previous CXR, date & results, TB exposure.

Cardiovascular: chest pain, palpitations, orthopnea, (quantitate), PND, murmur, ankle edema,
claudication, exercise tolerance, hypertension, lipid disorders, ECG.

Breasts: pain, masses, nipple discharge, performs breast self-examination (BSE)

GI: pain, change in appetite, nausea, vomiting, hematemesis, diarrhea, constipation, melena,
hematochezia, change in stool color or caliber, history of hepatitis, peptic ulcer disease or gall bladder
disease, jaundice, food intolerance, hernia.

GU: dysuria, frequency, urgency, hematuria, hx of UTI, nocturia, change in stream, incontinence
discharge, hx of STD's, testicle pain/lumps, TSE, erectile function.

GYN: menarche, LMP, duration, quantity and interval of menses, menorrhagia, dysmenorrhea, discharge,
last Pap, menopause, contraception, libido, dyspareunia,
Pregnancy hx: "GPAL" Gravida (number or pregnancies), Para (number of deliveries), Abortions
(spontaneous or therapeutic or elective) Living (children).

Heme: hx anemia, easy bruising or bleeding, recurrent infections, adenopathy, hx of bleeding or clotting
disorders

Lymphatic: swollen nodes, pain or inflammation.

Endocrine: heat or cold intolerance, easy fatigability, polyuria, polydipsia, polyphagia, thyroid problems,
hair changes.

Musculoskeletal: joint pains, erythema, swelling, decreased function, myalgia, back pain, arthritis,
cramps.

Neuro: dizziness, vertigo, syncope, seizures, paresthesias, dysesthesias, imbalance, tremors, impaired
memory or speech.

Psych: anxiety, depression, hallucinations, suicidal or homicidal ideation, hx suicide attempt, psychiatric
care or hospitalization.

Smith’s Patient Centered Interviewing Text