English for Medical History Taking

Introducing Yourself
[Shake their hand, giving your name and, if you are a student, give your medical school
status (what year you are in as a student etc.).
Identifying Information (ID)
[If you do not see the patient's name on charts or whiteboard, asking the patients name.!
"hat is your name, please# or $ay I have your name, please#
[If you have a record of the patients name, checking the information.!
%i, $iss &ones# or
%i, is it $iss &ones#
'sking for the patients permission to take a history (consent)
Is that okay with you today to talk#
I'm going to start out today by (ust talking a little bit with you about your chief complaint.
Chief Complaint (CC)
"hat brings you here today#
['fter hearing the )hief )omplaint!
*efore we talk a little bit more about that (chief complaint), is there anything else that you
want to talk about with me today#
History of the Presenting Illness (HPI)
+resenting +rincipal Symptoms (+S) or +resenting )omplaint (+)) , establishing what the
patients principal symptom is.
Time of onset of ymptom
"hen did you first notice the problem# (-ate . time) or
"hen did the [pain! first appear# /r
"hen did it start for you#
%as it changed over time#
Duration
%ow long did.does the pain last#
Mode of !nset
-id the pain come on suddenly or gradually#
-o you recall what you were doing at the time that it started#
ite of ymptom
"here do you feel the pain# )an you point e0actly to where it is for me, the
location of it e0actly#
Character
-oes the pain feel burning, dull or sharp#
e"erity of ymptom
/n a pain scale of 1 to 12, 12 being the worse pain you've ever had. 1 or 2 being no
pain. %ow bad is this pain#
-oes anything make it worse#
Is there anything that makes your symptoms better#
#uantify e"erity
If the patient presents with shortness of breath
%ow far can you walk before feeling out of breath#
%ow many stairs can you walk up before feeling out of breath#
!ther #uestions
"hen did you last feel fit and well#
%ow do you feel at the moment#
%ave you seen a doctor before for the same problem# /r %ave you seen anybody
else for this complaint#
Past Medical History (PMH)
Id like to ask some 3uestions about previous medical problems you have had.
Starting from when you were a child, have you had any serious illnesses,
operations, hospital visits#
're you up to date on all your immuni4ations#
Drug History (DH)
Id like to ask some 3uestions about any medicines you are taking at the moment.
're there any medications that you take every day#
-o you know the name of the medicine#
%ow much do you take#
%ow often do you take it#
-o you take any non,prescription medicines# 'nything that you buy from a
pharmacy#
-o you take any herbal medicine or traditional medicine#
-o you take any vitamins#
're you allergic to any medications#
$amily History ($H)
5ow I want to talk about your family history. "hen I talk about family history, I mean your
parents, your grandparents, and your children.
're your parents and your grandparents your biological parents#
're there any illnesses that run in your family that you know about#
're both your parents living# "hat are their ages# 'nd do they have any health
problems that you're aware of now#
'nd your children, do they have any health problems that you're aware of#
ocial History (H)
5ow, I'd like to talk with you about you and your lifestyle. If for some reason you're uncomfortable
answering something, please (ust let me know.
)an you tell me where you were born and raised#
'nd how long did you live there#
"ho lives with you#
-o you have family and friends living near you or the surrounding area#
%ow many hours a day do you work#
"hen you are not working, how do you spend your time#
"hat do you do for leisure, for fun#
)ould you tell me what you usually eat for meals and for snacks in a typical day.
're there are any groups of food that you either eat too much of or that you stay away
from#
)an you tell me about your caffeine use, coffee, colas#
-o you take regular e0ercise# 6ell me about that#
%ow many hours of sleep a night do you get# Is it restful sleep#
-o you nap during the day#
I would like for you to give a little thought to either your living situations or your working
situations. -o you have any e0posure to things like smoke, fumes, chemicals, radiation,
loud noise#
6he ne0t set of 3uestions that I need to ask you are more personal ones. +lease don't answer
anything that you feel uncomfortable with.
-o you have any tattoos or piercings# In which country did you have them done# %ow long
ago#
-o you smoke tobacco# "hen did you start to smoke# %ow much do you smoke#
-o you drink alcohol# "hat type of alcohol do you drink# %ow much do you drink#
-o you use any recreational drugs#
I want to talk with you a little bit about your se0ual health. 're there any se0ual health
concerns that you have#
're you se0ually active# [If no! , "hen was the last time you were# 'nd when you were
se0ually active, were your partners men, women or both#
"hat did you do and at what age did you become se0ually active#
-o you have any concerns about hepatitis or %I7 e0posure# 'ny concerns about your
se0ual health now at all#
'ny other areas in your life in terms of stress that you're worried about#
%e"ie& of ystems (%)
I want to talk about you a little bit about something we call a review of systems, and this is
the last part of our interview where I ask some short 3uestions about you health.
%as there been any change in your weight either up or down#
're you satisfied with your current weight#
'ny problems with fever or chills#
'ny problems with night sweats or une0plained fatigue#
I want you to think about your skin. 'ny problems with rashes#
'ny lumps or bumps#
'ny itching#
'ny change in your hair, for e0ample have you lost hair or your hair seems dryer#
'ny changes in your nails# 're your nails more brittle# -o they grow normally# -o
you have little holes, what we call little pitting in them#
'ny change at all in your moles or your freckles#
-o you use a sunscreen when you go out in the sun#
5ow I want to talk about your eyes a little bit. ["earing glasses! "hen is the last
time you saw an ophthalmologist.optician#
'ny pain in your eyes#
'ny tearing (watery eyes) or dryness#
'ny double or blurred vision#
&ust a few 3uestions about your nose. 'ny complaints of a runny nose or being
stuffed up all the time#
'ny history of nose bleeds#
I want to talk about your ears. 'ny ringing in your ears#
'ny di44iness#
'ny pain in your ears#
'ny loss of hearing#
-o you have any pains or sores in your mouth#
"hen is the last time you saw a dentist#
'ny bleeding at all of your gums#
'ny hoarseness, do you feel like you're losing your voice all the time#
8emales9
-o you do self,breast e0ams#
5otice any lumps or bumps or cysts in your breasts#
'ny discharge from your nipple#
'ny pain in your breasts at all#
Cardiorespiratory
I want to talk about your lungs. 'ny coughing all the time#
-o you cough anything up#
-o you ever cough up blood#
-o you ever feel short of breath#
-o you ever whee4e#
5ow about your heart, do you ever have chest pain#
:ver feel like your heart is beating so fast it's uncomfortable#
'ny shortness of breath when you sleep at night#
-o you notice that you have to sleep sitting up to be more comfortable, or are you
able to lie flat#
'ny pains in your calves after you walk for a period of time#
'ny swelling in your legs#
Chief Complaint specific 'uestions(
Chest and lungs
)ough
Duration9 %ow long have you had the cough#
Mode of onset9 -id the cough come on suddenly or gradually#
Severity9 -oes anything make the cough worse# Is the cough made worse by
e0ercise# Is the cough made worse by lying down# Is the cough worse at night# %ave
you had a fever#
Influence of posture9 -o you cough more if you are lying on your side# -o you
cough more if you are leaning forwards#
Production9 -oes anything come up when you cough#
Constancy9 %as your cough changed since it first started#
Paroxysms9 -o you have sudden coughing attacks# %ow often do you have these
coughing attacks# %ow long does each attack last#
Dyspnoea9 -oes it hurt to breathe or take a deep breath# %ave you had any shortness
of breath#
Morning cough9 -o you cough in the early morning after you wake up#
Clearing throat9 -o you fre3uently have to clear your throat or swallow mucus#
Sputum
Amount9 -o you cough up a small or large amount of mucus.phlegm#
Constant9 're there times of the day when you produce more mucus.phlegm#
Periods of freedom9 %ave there been times when you havent produced any
mucus.phlegm#
Colour9 "hat is the colour of the mucus.phlegm#
Consistency (stringy, mucoid, chunky9 "hat is the consistency of the mucus.phlegm
!dour9 -oes it smell bad#
"loodstreaked9 %ave you noticed any blood in your mucus.phlegm#
#aemoptysis9 -escribe fully. -istinguish from haematemesis and other sources of
bleeding as, from pharyn0.
Sensation of $eight, tightness, dyspnoea in chest9 -o you have any sensations in your
chest; for e0ample do you have a feeling of weight, or tightness, or difficulty
breathing#
#istory of previous chest illnesses9 "hat other chest illnesses have you had in the
past# %ow often do you get chest colds# %ow long do they usually last# %ave you
ever had pleurisy, bronchitis, asthma, pneumonia#
#istory of exposure to persons $ith tu%erculosis9 %ave you ever been e0posed to
people with tuberculosis#
Heart
&xercise tolerance9 -oes ordinary e0ercise cause any distress such as9 difficulty
breathing (dyspnoea), pain in your chest (praecordial pain), tightness over the chest
(praecordial oppression), or e0cessive tiredness (undue fatigue)#
If there is any limitation9 %ow much e0ercise produces these symptoms#
Compare recent $ith previous exercise tolerance9 %as there been any changes in the
amount of e0ercise you can do now and in the past#
-yspnoea
At rest9 -o you have difficulty breathing when you are resting#
'octurnal9 %ave you ever woken up and been unable to breathe#
Paroxysmal9 -o you e0perience sudden shortness of breath or difficulty
breathing#
'ature of symptoms9 %ow often does this happen# %ow long does it last
for#
Cardiac asthma9 -o you e0perience whee4ing#
Sighing9 -o you feel the need to take fre3uent deep sighs#
6achycardia (palpitation)
!n exercise9 -o you e0perience palpitations when you e0ercise#
(achycardia (palpitation at rest9 -o you e0perience palpitations when you
are resting#
'ature of symptoms9 -o these palpitations come on slowly or suddenly# 're
they fast or slow palpitations# 're they regular or irregular palpitations#
%ow long do they last for# -o they stop suddenly or gradually# %ow often
do you get them#
+raecordial or substernal pain or other distress
!n exercise9 "hen you e0ercise do you e0perience pain or any other
discomfort in you chest area or below your sternum#
At rest9 "hen you are resting do you e0perience pain or any other
discomfort in you chest area or below your sternum#
&xact location9 "here do you feel this pain or discomfort e0actly#
Severity9 /n a scale of 1 to 12 describe your pain.
Duration9 %ow long does the pain last for#
)adiation9 -oes the pain or discomfort move to another part of your body#
Pallor9 -oes your skin become pale#
Cyanosis9 -oes your skin turn blue#
S$eating9 -o you start sweating#
*aintness9 -o you feel faint
+eakness9 -o you feel weak#
'ausea or vomiting9 -o you feel sick or need to vomit.throw up#
S$elling of ankles and legs9 -o your ankles and legs swell up# -oes it clear up with
rest# Is it increasing# %ow long have you e0perienced swelling of you ankles and
legs#
+revious history indicative of rheumatic disease
*litting (Migratory arthritis9 %ave you e0perienced pain and swelling
going from (oint to (oint over a period of days#
*re,uent sore throat9 -o you get a lot of sore throats#
-ro$ing pains9 %ave you e0perienced any aches and pains in your arms and
legs#
Chorea9 %ave you e0perienced any involuntary, (erky movements of you
body; for e0ample, your arms, legs and face#
)enitourinary ystem
*rinary system
'ny urination changes for you, for e0ample, that you urinate more fre3uently#
'ny feelings like you have to go all the time#
%ow often do you urinate during the day# %ow much urine do you pass#
%ow often do you urinate at night# %ow much urine do you pass#
Is there any recent change in how often you urinate, or how much do you urinate#
"hen did these changes first occur#
-o you feel any pain or burning when you urinate#
If I had to ask you to stop the flow of your urine, you could stop it#
(Precipitancy -o you feel you suddenly have to urinate without warning#
(.rgency -o you feel a strong need to urinate#
(#esitancy -o you find it difficult to start urinating#
(Dri%%ling -o you find that you can only pass a small amount of urine at a time#
(Incontinence -o you find that you can not hold on to your urine#
()etention -o you find it difficult to start urinating or to completely empty your
bladder#
)haracter of urine
"hat is the colour of your urine#
%as there been any change in the smell of your urine#
%ave you noticed any blood in your urine#
%ave you noticed any pus in your urine#
%istory of renal colic
%ave you passed any sand or stones in your urine#
%istory of haematuria
%ave you passed urine that is red or a dark cola colour#
)enital system
In males9
%ave you ever had any venereal diseases#
%ave you had treatment for any venereal diseases# (%ave you ever had a venereal
infection#).
%ave you ever had any pus discharge from your penis#
(Symptoms of stricture) see <rinary System = %esitancy, -ribbling and >etention.
%ave you ever had a urinary tract infection#
In females9
't what age did you start menstruating# ('t what age did you start your period#).
"hat is the time interval between your menstruations# ("hat is the time interval
between your periods#).
Is your menstrual cycle regular# ('re your periods regular#).
%ow long does your menstruation last for# (%ow long does your period last for#).
-o you have heavy, medium or light blood loss during your menstruation# (-o you
have heavy, medium or light blood loss during your periods#)
%ow much pain do you feel during your menstruation# (%ow much pain do you feel
during your periods#).
%ow much does your menstruation affect your day to day life# (%ow much do your
periods affect your day to day life#).
're you going through your menopause#
-o you have any bleeding between your menstruations# (-o you have any bleeding
between your periods#).
-o you have any discharge between your menstruations# (-o you have any
discharge between your periods#).
"hat is the colour of this discharge#
%ow much discharge do you have#
"hat is the odour (smell) of this discharge#
"hat is the consistency of this discharge#
%ave you ever had a venereal disease# (%ave you ever had a venereal infection#).
%ave you ever been pregnant#
%ow many times have you been pregnant#
%ave you ever had a miscarriage#
%ow many times have you had a miscarriage#
't how many weeks did the miscarriage(s) occur#
%ave you ever had an abortion#
%ow many abortions have you had#
%ow many children do you have#
Central ner"ous system
State of mind9 %ow have you been feeling recently; for e0ample, contented, worried,
irritable, depressed, agitated, or e0periencing any crying spells# 'ny periods of where
you (ust didn't feel you could en(oy your life very much#
Memory9 %ow is your memory# %ave you e0perienced any problems remembering
things from a short time ago or a long time ago#
A%ility to concentrate9 %ow is your concentration#
Distur%ances of sleep9 %ow have you been sleeping# %ave you had any problems
sleeping recently, for e0ample, periods of insomnia where you couldn't sleep#
%ave you had any sei4ures#
%ave you had any tremors where you're shaking#
%ave you had any numbness or tingling going anywhere#
'ny time where you feel like you lost speech or vision#
'ny episodes of increased sweating, increased thirst, increased urination#
)astrointestinal
"ith your stomach, any problems swallowing or feeling like you can't get food
down#
'ny complaints of heartburn, or is food coming back up#
'ny change in your appetite, more or less#
'ny nausea or vomiting#
'ny abdominal pain#
-o you ever throw up blood#
'ny presence of blood when you have a bowel movement, that you see blood in the
stool or in the toilet#
're your bowel movements ever dark black and sticky#
'ny constipation#
'ny diarrhea#
'ny foods that (ust do not go down well with you# 8or e0ample, does anything give
you more heartburn or indigestion#
'nybody ever told you that you look yellow to them or that the whites of your eyes
look yellow#