There are many methods and guides used for history taking and as time goes by you will develop your own style. Below are examples of a Medical History:

Classical Medical History

1. Chief Complaint: chronological narrative of problem.

   1. onset

   2. quality

   3. severity

   4. timing (duration, frequency)

   5. what makes worse/better

   6. associated manifestations

2. Past Medical History

   1. general state of health

   2. childhood illnesses

   3. immunizations

   4. adult illnesses

   5. psychiatric illnesses

   6. surgeries

   7. injuries

   8. hospitalizations

   9. ALLERGIES

3. Current Medications

4. Diet

5. Sleep Pattern

6. Habits

   1. smoking

   2. dipping

   3. ETOH intake

7. Family History

   1. HTN

   2. TB

   3. HA

   4. Stroke

   5. heart disease

   6. diabetes

   7. mental illness

8. Psychosocial History

   1. life style, home situation, significant others

   2. school

   3. job

   4. financial

   5. recreation

9. Review of Systems

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   1. General

      1. usual weight

      2. weight change

      3. weakness, fatigue, fever

   2. Skin

      1. rashes

      2. lumps

      3. itching

      4. dryness

      5. color changes

      6. hair and nails

   3. Head

      1. HA

      2. head injury

   4. Eyes

      1. vision

      2. corrective lens use; type

      3. last eye exam

      4. pain

      5. redness

      6. tearing

      7. double vision

   5. Ears

      1. hearing

      2. tinnitus

      3. vertigo

      4. pain, earache

      5. infection

      6. discharge

   6. Nose & Sinuses

      1. frequent colds, nasal stuffiness

      2. hay fever, atopy

      3. nosebleeds

      4. sinus trouble

   7. Mouth & Throat

      1. teeth and gums

      2. last dental exam

      3. sore tongue

      4. frequent sore throat

      5. hoarseness

   8. Neck

      1. lumps in neck

      2. pain

   9. Breasts

      1. lumps

      2. nipple discharge

      3. pain

      4. self-exam

   10. Respiratory

       1. cough

       2. sputum (color, quantity)

       3. hemoptysis

       4. wheezing

       5. asthma

       6. bronchitis

       7. pneumonia

       8. TB, last PPD

       9. pleurisy

       10. last CXR

   11. Cardiac

       1. heart trouble

       2. HTN

       3. rheumatic fever

       4. heart murmurs

       5. dyspnea/orthopnea

       6. edema

       7. chest pain/palpitations

       8. last EKG

   12. Gastrointestinal

       1. trouble swallowing

       2. heartburn

       3. appetite

       4. nausea

       5. vomiting

       6. vomiting blood

       7. indigestion

       8. frequency of BM’s, last BM, change in habit

       9. rectal bleeding or tarry stools

       10. constipation

       11. diarrhea

       12. abdominal pain

       13. food intolerance

       14. excessive belching or farting

       15. hemorrhoids

       16. jaundice, liver or gall bladder trouble, hepatitis

   13. Urinary

       1. frequency of urination

       2. polyuria

       3. nocturia

       4. dysuria

       5. hematuria

       6. urgency, hesitancy, incontinence

       7. urinary infections and STD’s

       8. stones (renal calculi)

   14. Genito-reproductive

       1. MALE

          1. discharge from or sores on penis

          2. STD hx and treatment, Last HIV test

          3. hernias

          4. testicular pain or masses

          5. frequency of intercourse, libido, difficulties

       2. FEMALE

          1. 1st menarche, regularity, frequency

          2. flow duration, amount

          3. bleeding between periods or after intercourse

          4. last PAP, results

          5. number of pregnancies, deliveries, abortions (spontaneous & induced)

          6. STD’s hx and treatments, Last HIV test

   15. Musculoskeletal

       1. joint pain/stiffness, arthritis, backache.
          (describe location and swelling, redness, pain, weakness, ROM)

       2. past injuries, treatments

   16. Neurologic

       1. fainting, blackouts, seizures, paralysis, weakness, numbness, tingling, tremors, memory

   17. Psychiatric

       1. mood, affect

       2. nervousness, tension, depression

       3. past care

   18. Endocrine

       1. thyroid trouble

       2. heat or cold intolerance

       3. excessive sweating, thirst, hunger, urination

       4. diabetes

   19. Hematologic

       1. anemia

       2. ease of bruising, bleeding

       3. past transfusions and any reactions

ANOTHER FASTER WAY TO TAKE A MEDICAL HISTORY IS BY USING THE KEY WORD "SAMPLE PQRST"

S: Symptoms
A: Allergies
M: Medicine taken
P: Past history of similar events
L: Last meal
E: Events leading up to illness or injury

P: Provocation/Position - what brought symptoms on, where is pain located.
Q: Quality - sharp, dull, crushing etc...
R: Radiation - does pain travel
S: Severity/Symptoms Associated with - on scale of 1 to 10, what other symptoms occur
T: Timing/Triggers - occasional, constant, intermittent, only when I do this. (activities, food)

EXAMPLE:

Hospital Corpsman Sickcall Screeners Handbook

Naval Hospital, Great Lakes

April, 1999

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Operational Medicine 2001

Health Care in Military Settings

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