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Comprehensive Patient History Guide

The document outlines the typical steps and questions involved in taking a patient's medical history. It includes questions about the patient's: name, date of birth, address, occupation, phone number, health insurance, chief complaint, details about the complaint, past medical history, immunization history, allergies, current medications, family medical history, smoking and drinking habits. The goal is to gather relevant information about the patient's health to inform the doctor's assessment.

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Angga Prabawa
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7 views2 pages

Comprehensive Patient History Guide

The document outlines the typical steps and questions involved in taking a patient's medical history. It includes questions about the patient's: name, date of birth, address, occupation, phone number, health insurance, chief complaint, details about the complaint, past medical history, immunization history, allergies, current medications, family medical history, smoking and drinking habits. The goal is to gather relevant information about the patient's health to inform the doctor's assessment.

Uploaded by

Angga Prabawa
Copyright
© All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd

RECAP

A. History Taking
Hii !!, Good Evening, I’m Doctor Angga. I’m doctor on duty today. Have a seat please
D: What’s your name? Can you spell it for me, please?
What should I call you?
D: What’s your date of birth?
D: What’s your address / Where doyou stay?
D: What’s your occupation?
Work  is your work stressful ?
Retired  how long have you been retired?
D: Your phone number please?
D: Do you have health insurance? I need to make copy it, please
D: Chief complaint : What’s brought you along today?
D: Chronology: Can you tell me more about your complaint?
D: Onset : When it started?
Did this problem start slowly or it come quite suddenly?
D: Location : Where does it hurt?
Which part of your body is affected?
D: Quality : Can you describe the pain for me ? (is it stubbing or burning )
D: Quantity: On scale one to ten, how would you rate the pain?
D: Modification factors : Does anything make it better / worse?
D: Comorbid complaints : Is there anything else you feel at the same time?
D: Would you tell me about your bowel motion and waterworks?

D: Do you have any past medical history I should concern of ? (DM, HD, RD)
Yes  How long have you hade this condition?
Are you seeing a doctor for this condition?
Are you taking any medication for this condition?
Can you tell me about the name of the medication?
Do you know the dosages you take?
How often do you take this medication?
D: Have you ever had kind of disease? ( Mumps, measles, TB, diphtheria)
D: Have you ever got any immunization?
D : Are you allergic to a certain food or medication? What happen to you?
D: Are you taking any prescription medication? (pills, injection, inhalers)
Do you use any alternative treatments ?
Are you taking any over the counter medicines?
D: Do your parents have any health problem ? how old are they?
Passed away: I’m sorry to hear that, what was the cause of your parent death?
How old was she (he) when she (he) died?
D: Do you have any brother or sisters ? how old are they? Do they have any health problem?
D: Is there a history of ( high BP, cancer, asthma, diabetes, etc) in your family?

D: Do you smoke?

D: Do you drink beer, wine?

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