History Taking
Template
Wash your hands
Introduce yourself
Ask permission to take a history
General information
Name:
Age:
Sex:
Occupati
on:
Presenting Complaint:
A short phrase describing the presenting complaint in the patient's own
words
History of Presenting Complaint:
Mnemonic - SOCRATES for pain
Site - Where is the pain?
Onset - When did the pain start, and was it sudden or gradual?
Character - What is the pain like? An ache? Stabbing?
Radiation - Does the pain radiate anywhere?
Associations - Any other signs or symptoms associated with the pain?
Time course - Does the pain follow any pattern?
Exacerbating/Relieving factors - Does anything change the pain?
Severity - How bad is the pain?
Need to explore the presenting complaint chronologically and incorporate
relevant systems enquiries.
Ex: Chest pain - need to explore cardiovascular, respiratory and GI
systems enquiry in the history of presenting complaint as pathology
from all of these systems could cause chest pain.
Systems Enquiry
Specific questions for each system – must be asked for every patient
CARDIOVASCULAR RESPIRATORY GASTROINTESTINAL
Chest pain SOB Abdominal pain
Palpitations Cough Diarrhea/ Constipation
SOB/ SOBOE – quantify Sputum production Dyspepsia/ heartburn
Orthopnea Chest pain Dysphagia
Paroxysmal Nocturnal Hemoptysis Hematemesis/ melena
Dyspnea
Intermittent claudication Wheeze Rectal bleeding
Oedema Jaundice
GENITOURINARY NEUROLOGICAL LOCOMOTOR
Hematuria Headache Falls
Dysuria Dizziness Arthralgia
Increased free micturition Visual disturbance/ Joint stiffness
diplopia
Nocturnal Speech disturbance Rashes
Hesitancy/ dribbling Hearing disturbance Mobility
Polyuria Weakness Functional deficit
Vaginal discharge Paresthesia
Intermenstrual bleeding Numbness
Menstrual cycle Cramps
Past Medical/Surgical History
Mnemonic – JAM THREADS
J - jaundice
A - anaemia & other hematological conditions
M - myocardial infarction
T - tuberculosis
H - hypertension & heart disease
R - rheumatic fever
E - epilepsy
A - asthma & COPD
D - diabetes
S - stroke
Other:
Drug History/Allergies
Names and doses of all
Drugs Compliance
Allergies – nature of allergy very important
Family History
First degree relatives
Any significant medical problems
If deceased – Age at which deceased and cause of death
Social History
Smoking:
Current/ Ex-smoker
Pack years – Age started smoking, number of cigarettes per day
Alcohol:
CAGE questionnaire
Quantify number of units per day/week
Any episodes of alcohol withdrawal
Home circumstances:
Independent/ dependent for activities of daily living – washing/
eating/ shopping/ cleaning
Stairs/ toilet on ground floor/ bedroom on ground floor
Mobility – with/ without aids
Careers
Social support – who do they live with? Family close by?
Examination
See separate sheet
Tests
Document systematically
Bedside investigations i.e. urine dipstick/ ECG/ BM
Blood test results
Radiology
Impression
What is your overall impression and list your differential diagnoses?
Plan
Further investigations:
Bedside tests
Blood tests
Radiology
Specialist investigations
Management:
A clear plan of management for the next 24 hours including
interventions (i.e. antibiotics, fluids)
You should also outline a longer term management plan (i.e.
further investigations that may be required)
Clear parameters for aims of treatment – BP/PR/RR.
Clear indications of when the nursing staff should contact doctors
A clear plan for what to do in the event of deterioration
Document any discussions about management with senior
colleagues and colleagues from other specialties
Document discussions with the patient and their relatives
about the patients managemen
To complete your documentation:
Sign and date your history at the bottom and clearly (and
legibly) document your grade and your nam
