HISTORY TAKING - When did this start?
3. Location & Region/Radiation
OPENING PORTION - Where is it? Does it radiate?
1. Greet patient and address appropriately by using 4. Character
Mr., Mrs., or MS., or his/her title. - What is it like? Describe.
2. Introduce self 5. Aggravating/Alleviating factors
3. “Can I address you as Maam/Sir _____ etc” - Is there anything that makes it better or
4. Ask patient his/her preferred language or dialect. worse?
5. Purpose of interview and how long will it take 6. Timing & Duration
- I am here to ask about what you have been - When did it start?
feeling these past few weeks. I will ask - How long does it last?
questions. This will help us make a diagnosis - How often does it come?
and decide which laboratory tests and 7. Severity/Scale
ancillary procedure are needed as well as - How bad is it? (for pain, ask for a rating on a
which treatment is appropriate for you. This scale of 1 to 10)
will take about 10-15 minutes. 8. Did you take any medications to alleviate your
6. Explain the need to take notes and ask if this is condition?
acceptable. 9. Did you consult a medical expert on this?
- Will it be okay if I take some notes? I need to
take some notes for me not to forget TERTIARY HISTORY
anything. Do not worry this will all be
confidential. TERTIARY HISTORY: Past History
7. Get informed consent Birth and Developmental History
- Is it okay for me to take your history? 1. Age of the mother during pregnancy
2. Manner of delivery, Birth Weight, Complications
INFORMATION GATHERING Childhood & Adult Illness/ Hospitalizations
- Have you been hospitalized recently? Or
GENERAL DATA: NASEOMADR during the past years?
1. Name 3. Date/year – hospital/home
2. Age 4. Signs and symptoms
3. Address 5. Diagnosis
4. Sex 6. Medications
5. Ethnicity 7. Consultation done
6. Occupation Injuries/Accidents
7. Religion - Have you been involved in any accidents? Or
8. Marital status experienced any injuries?
9. Date of examination 8. Date/year – hospital/home
9. Nature of injury
PRIMARY HISTORY 10. Type of surgery
Chief Complaint: 11. Complications
1. Tell me about your problem. 12. Diagnosis
- Note: If the CC of the patient is a neurologic Blood Transfusion
problem, ask for the handedness. 13. Date/year – hospital
History of Present Illness: OLD CARTS 14. Type of blood product & number of units
2. Onset 15. Indication
16. Complications/reactions Sleep Pattern
Allergies 3. Usual number of hours of sleep
17. Drug related - Snoring
- Class of medication - Easily interrupted
- Symptoms - Immediately falls asleep
- Date of last occurrence - Insomnia
18. Non drug related - Feeling upon waking up: rested, feels sleepy,
Obstetric/Gynecological History tired
19. Obstetric Exercise
- Have you ever been pregnant? Full term, Pre 4. Do you exercise? If NO proceed to the next. If
Term, Abortion, Live YES ask the following:
- Year of birth - Type
- Age of gestation - Frequency per week
- Form of delivery - Duration per session
- Place of delivery - Regularity
- Complications Smoking
20. Gynecologic 5.
- Menarche (age) menopause (age)
- Menstrual flow interval (days), regularity
- Duration of menstrual days, amount
(pads/day)
- Last menstrual period (date)
- Dysmenorrhoea
- Age of first sexual contact
- Sexually active
TERTIARY HISTORY: Current Health Status
Heath Screening
1. Prior blood tests or ancillary procedures not Alcohol
related to present illness 6. Do you drink alcohol? If NO proceed to the next.
- Date If YES ask the following:
- Results/abnormalities - Type of alcohol
Nutrition/Dietary Habits - Volume consumed per session
2. - Frequency per week
Environmental Exposures
7. Have you travelled anywhere recently or in the
past years?
- Place, date, duration of exposure, activities
Medication Data
8. Self-prescribed/OTC
- Name of drug
- Date started or duration of intake
- Date stopped
- Preparation
- Dosage/frequency
9. Doctor Prescribed TERTIARY HISTORY: Personal and Social History
- Name of drug
- Date started or duration of intake
- Date stopped
- Preparation
- Dosage/frequency
10. Herbal medications
11. Illegal drug/substances
Immunization
1. Childhood & Adult Immunizations
CLOSING PORTION
1. Thank the patient for his/her time and
cooperation.
TERTIARY HISTORY: Family History
1. Health status:
- Parents (Are you parents well?)
- Siblings
- Children
- Relatives
2. Death
- Cause
- Age of death
