Introduction and Patient Demographics

The physician should identify themselves and their role.  The patient’s age, gender and marital status should be recorded. 

Chief Complaint

Identify the major problems and establish the reason for the visit.  Get the patient to describe in their own words why they have sought medical attention.

History of the Presenting Illness

Explore the important symptoms: determine their onset, duration and time course; establish location, quality, quantity, setting, aggravating and alleviating factors, associated manifestations and the effect of therapy. 

Explore their feelings about the illness; their ideas about the current problem (do they think it is related to work or another activity?); how it is impacting their daily functioning (are they worried about performing at work or home?) and their expectations from the visit.

Medication History

Current and past medications, over the counter medications, vitamins and supplements need to be asked about and recorded. Ask also about any drug allergies – find out which drug and note the reaction when it is taken.

Habits

Including dietary patterns,sleep patterns, exercise, use of caffeine, tobacco, alcohol,and non-prescription drugs.

Screening questions are asked to search for problems in other body systems.

Past Medical History

A review of past medical and surgical illness, which has not been previously covered, should be included. Any conditions that a patient may have been previously diagnosed with that may predispose them towards having one particular disease versus another should be specifically inquired about.

Family History

The ages, states of health or cause of death of mother, father, siblings, spouse and children and any hereditary illnesses that run in the family should be inquired about.

Current Life Situation

Explore the family system and living situation. Any emotional stresses at work or economic pressures could be contributing to the development of a work-related disease. Household chores and hobbies should also be discussed and the movements involved in tasks and any exposures clarified if necessary.

References

1.Year 2 Clinical Methods Handbook. 1999. Faculty of Medicine and Dentistry, University of Western Ontario. London, Ontario.