The History Taking skill
1) Chief complaints
All the complaints by the patient or family should be noted.
It should be in descending order of time of symptoms
2) History of presenting illness- Ask about the following in brief
- 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- in children above 12 years or as appropriate