Scribd
Upload
21 views

History Taking Checklist

Uploaded by

bhakti kharate
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
21 views

History Taking Checklist

Uploaded by

bhakti kharate
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
You are on page 1/ 3

Check list

History Taking

STEP/TASK Y N
Preparation
1. Greet the patient and introduce yourself.
2. Explain the procedure, reassure the patient and get patient’s consent.
3. Make sure the patient is in a comfortable position sitting or lying down.
4. Maintain good eye contact and establish rapport with the patient.
HISTORY
Personal Information
5. Ask for the patient’s Name, Age, Gender, Occupation, Nationality, and Address.
Presenting Complaint:
6. Ask the patient about the main problems that made him/her went to see the
doctor.
History of Present Illness
7. Allow the patient to provide an account of recent events in his/her own words
without interruption.
8. Describe onset, course, duration; precipitating, radiating, and aggravating
factors; and associated signs and symptoms. (Use the SOCRATES, in case of
pain)
Important associated symptoms , risk factors , and if previously investigated for
the same problem
Ask the patient about history of any chronic problems like( DM, HTN , renal , or
cardiac diseases ……) when diagnosed , medications , follow up and any
complication related to the chronic disease
Past Medical History
9. Ask about any similar episodes in the past.
10. Ask about previous hospitalizations, allergy, blood transfusion, and trauma
history.
Family History
11. Ask about significant illness in the family. Similar illness in the family.
Personal and Social History
12. Occupation , education , socioeconomic status
Ask about use of alcoholic beverages, cigarette smoking or illicit drugs.
13. Ask politely about emotional problems at home or at work.
Obstetric and Gynecologic History (if patient is female)
14. Ask about the LMP (last menstrual period), regularity and quality of
menstruation. Ask age of menopause if patient is elderly.
15. Ask about number of pregnancy, abortion, number of children, and history of
complications during pregnancy.
Systemic Review (inquiry about all the cardinal symptoms in each of the major
systems)
16. Cardio-‐respiratory symptoms
 Ask about having cough, shortness of breath, chest pain, ankle
swelling, etc.
17. GIT symptoms
 Ask about having weight loss, nausea or vomiting, changes of bowel
movement, abdominal pain, etc.
18. Neurological symptoms
 Ask about having headache, dizziness, ringing in the ears, changes
in hearing, vision, smell or taste, etc.
19. Urinary and Reproductive symptoms
 Ask about having burning on passing urine, frequency of urination,
blood in the urine, etc.
 Ask about having penile or vaginal discharge, hesitancy or urgency
of urination, poor urine stream or dribbling, etc.
20. Dermatologic symptoms
 Ask about having skin rashes, redness, or itchiness, etc.
21. Musculoskeletal symptoms
 Ask about having joint pain or stiffness, muscle pain or weakness, etc.
Closing
22. Make explanations to the patient, answer questions and discuss management
plan. If appropriate, order diagnostic investigations (e.g. ultrasound scan, CBC,
LFTs, etc.).
23. Ensure that the patient is comfortable.
24. Thank the patient. Wash hands and document the procedure.

You might also like