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 How to take a medical history?

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PostSubyek: How to take a medical history?   Wed Feb 02, 2011 11:02 pm

A- Personal history:-

1- Complete name
2- Sex
3- Age
4- Occupation
5- Address
6- Marital state
7- Special habits of medical importance
8- Menstruation

B- Complaint:-

Patient main complaint in his own words with avoidance for multiple complaints

C- History of present illness:-

Starting from the last time at which the patient was completely healthy, we mention the symptoms and analyze each of them according to
1- Onset “Acute – gradual – Accidental”.
2- Course “Regressive – progressive – stationary – remission and exacerbation”.
3- Duration “Short – long”

D- Past history:-

We mention previous illness, similar attacks, surgical operations, drug treatment and blood transfusion.

E- Family history:-

We mention any history of consanguinity or similar conditions in the patient’s family.

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PostSubyek: Re: How to take a medical history?   Thu Feb 03, 2011 9:49 pm



1. identity

2. main complaint (that brings patient to the doctor)
pay attention to the time when the complain occurs (acute or chronic)
for acute complaints, we describe its insult (the characteristic of the complaint when it o
ccurs), and as for chronic complaints, we describe it chronologically

3. additional complaints

4. previous health history

5. family history

6. medicine and treatment history

7. current illness
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