History taking
History taking is an art and has to be practiced each time you see a patient. Below is the format
The History
1) Chief complaints
Should be in descending order of time of symptoms
2) History of presenting illness
- Mode of onset- Acute/ sub acute/ chronic
- Progress
- Duration
- Appetite
- Loss of weight/ fatigue
- Bladder/ bowel
3) Past history
- Rheumatic fever
- Tuberculosis
- Malaria
- Jaundice
- Systemic hypertension
- Diabetes
- Blood transfusions
- Hospital Admissions
4) Birth History
- Gestation at birth
- Complications at birth
- Immunization
5) Allergy history
- Allergens
- Medications used
- Severity of allergy
6) Family History
- History of similar problems in the family
- Pedigree tree(history of at least 3 consequent generations)
- Sudden deaths in the family
- Consanguinity
- Environmental factors- like smoking in the family in the case of wheeze.
7) Treatment history
- Any treatments so far
- Any surgical interventions
- Any medications being used
- Compliance to the medications
8) Menstrual history/ Obstetric history
- Menarche
- Duration of periods
- Dysmennorhoea/ Amenorrhoea/ Irregularities
- Last Menstrual date
- Sexual activity