History Taking Checklist
AY 2020 - 2021
Components of Medical Interview
Did the examiner perform: Yes No Remarks
In the opening portion:
1. Greet the patient and address patient
appropriately by using Mr./Mrs./Ms. or his/her
title.
2. Introduce himself/herself.
3. Explain his/her role. (medical student)
4. Provide a clear statement of the purpose of the
interview.
5. Ensure privacy.
6. Ensure patient was comfortable.
7. Express how long it will take and what is to be
done (history taking and PE).
8. Explain the need to take notes and ask if this is
acceptable.
9. Get informed consent (at least verbal) from the
patient
Information gathering:
1. Allow the patient to tell his/her story (patient
centered).
2. Used mainly open-ended questions.
3. Establish and maintain eye contact.
4. Establish narrative thread.
5. Expound on the problem/s.
6. Clarify.
7. Interrupt.
8. If the doctor took notes, was he/she able to do so
and still be able to demonstrate interest in the
patient?
9. Identify and respond to patient’s verbal cues.
10. Identify and respond to patient’s non-verbal cues.
11. Encourage patient to be relevant.
12. Ask close-ended questions after sufficient
database have been collected.
13. Progress from one section to another using
transitional statements.
14. Speak with respect.
Closing the interview:
1. Provide a summary of what the patient told
them.
2. Let the patient have the last word.
3. Give a pleasant “thank you” and “goodbye.”
Did the examiner ask: Yes No Remarks
A. General Data
1. Complete name (First, Middle, Last)
2. Age
3. Sex
4. Date of birth
5. Place of birth
6. Occupation
7. Nationality
8. Civil status
9. Religion
10. Contact information: complete address,
telephone number, cellular phone number,
email address
11. Consent maker
12. Source of referral: walk in, other MD, other
hospital
13. Health care plan available
14. Person to contact in case of emergency
15. Contact person’s contact number, address and
email
B. Chief Complaint (CC)
C. History of Present Illness (HPI)
1. Chronological order of events
2. Characterized symptoms (OPQRST)
3. Associated active medical, surgical or
psychiatric problems
4. Past experience with symptoms:
- Prior treatment, medications given, data from
past charts
- What has the patient done about the
symptom(s)?
5. Significant positives and negatives
6. Impact on activities of daily living (ADL)
D. Past History
1. Birth and developmental history
2. Childhood illness/hospitalizations
3. Immunization history
4. Adult illnesses/hospitalizations, including
psychiatric
5. Health screening
6. Medication review: self-prescribed/over the
counter (OTC); doctor prescribed; herbal
medications;
7. Surgeries
8. Injuries/accidents
9. Transfusions/reactions
7. Allergies
8. Obstetric/Gynecologic history including family
planning method
E. Family History
1. Current health of parents, siblings, children
2. History of significant illness (genogram if
needed)
3. Death: cause, date, and ages at death
F. Personal and Social History
1. Nutrition/dietary habits
2. Exercise
3. Smoking
4. Alcohol intake
5. Sleep pattern
6. Marital status/relationship
7. Family structure/living condition
8. Support/Secondary gains
9. Employment history/job satisfaction
10. Environmental exposures, recent travel,
chemical exposure
11. Sexual history/function
12. Significant life events, deaths, divorce, financial
hardships
G. Review of Systems (ROS)
1. General or constitutional symptoms
2. Skin/hair/nails
3. Head and neck
4. Breasts
5. Pulmonary
6. Cardiac
7. Abdominal
8. Genitourinary
9. Hematologic
10. Endocrine
11. Musculoskeletal
12. Vascular
13. Neurologic
14. Psychiatric
