History Taking – A General Template

Below is a general template for taking a history. In a nutshell, we should aim to introduce ourselves politely and start with an open question thus allowing the patient to describe in their own words what the problem is. After this we can work through the different categories obtaining information to gain a full perspective of the patient’s illness and obtaining the most likely differentials. Do not worry if you do not understand why we are asking all these questions, it will be explained in much more detail on the next page.

Introduction

• Good afternoon, my name is _______ and I am one of the student doctors here. Is it _______(patient’s name)?
• I just wanted to ask you some questions about how you are feeling and what has brought you in to see the doctor today, and then I’ll take that information, relay it to the consultant and we can go from there.
• Before I start, are you comfortable or would you likely me to get you anything? Do you mind if I take a seat?
• So, what has brought you in to see the doctor today?

(P) Presenting Complaint

• Summarise patient’s answer and ask first screening question) – Apart from this, have you noticed anything else?
• (Ask second screening question) – Ok, anything else?
• (Ask third screening question) – Before talking more about your [symptom], are there any other symptoms?
• (Last screening question) – Are you sure that there is nothing else?
• (Once we are sure there are no other questions, we can now address each symptom in turn) – Now I just want to ask some questions about the symptoms you have been feeling? Go through each symptom using OATES or SOCRATES for pain​

(I) Ideas, Concerns, Expectations

• Ok, you have been feeling these symptoms for some time, do you have any idea of what it could be?
• Are you particularly concerned about anything?
• What were you hoping to get out of the visit today?

(S) Systems Review

• (In response to them telling you their expectation from today’s visit) Ok, in order to do that, first I would like to ask you a few more specific questions just to get a more accurate picture of why you might be experiencing these symptoms.

• Specific Systems Review: (Ask specific questions regarding that system)

• General Systems Review: (Ask general questions to rule out red flags):
  (Fever) Have you got a fever?
  (Glands) Have you got any swollen glands?
  (Weight) Have you noticed any weight loss?
  (Appetite) Have you noticed any changes in your appetite?
  (Bowels) Have you experienced any changes in your bowel movements?
  (Waterworks) Are your waterworks all fine?
  (Tired) Have you been feeling more tired than usual?
  (Travel) Have you travelled anywhere recently?
  (Night sweats) Do you wake up in the night drenched in sweat?
  (Rash) Have you got any rashes?
  (If woman, and abdominal pain, enquire about pregnancy) Are you on the contraceptive pill? Is there a chance you could be pregnant?

(P) Past Medical History

• And now, about your health in general, have you ever seen your doctor about something like this before?
• Do you have any other medical conditions, such as diabetes, blood pressure or asthma?
• Have you ever had any surgeries?
• Have you ever been admitted into hospital before?

(F) Family History

• Is there any incidence of [Patient’s condition type] in your family?
• Are there any other conditions which run in your family?

(D) Drug History

• Are you currently taking any prescribed medication?
• Do you take anything else, over the counter?
• Do you have any allergies?

(S) Social History

• (Work) And now, a little but more about yourself in general, do you work at the moment? What do you do?
• (Home) Do you live with any family or friends? Are you married? Do you have any children?
• (Independence) Would you say that you are fairly independent?

And now these are some questions that we ask everyone:

• Do you smoke? (Have you ever smoked? / When did you start? / How many a day?)
• Do you drink? (How much a week? And for how long?)​
• Is there any recreational drug use?

Conclusion

• Ok, just to recap to make sure I haven’t missed anything (quick summary.)
• Thank you very much, I’ll relay this information to the consultant and then we can go from there. Do you have any questions?

Well done for making it to the end of the history. To understand why we are asking all these questions, please read on to the next page.