General History
The general history is organized into a series of sections, which when taken together, should form a comprehensive review of the patient’s entire medical history. The format of the history is typically as follows:
Identifying data (ID)
Chief complaint (CC)
History of the present illness (HPI)
Past medical history (PMH)
Family history (FH)
Social history (SH)
Identifying data (ID)
Patient’s name, age, sex, gender
If family members contribute to the history, document their names and relationships
Note if a translator is used
Chief complaint (CC)
Patient’s brief statement of why s/he sought medical attention, usually recorded in the patient’s own words
A good question to ask is «What is the reason you have come to the hospital/clinic today?»
History of the present illness (HPI)
Elaborates on the CC and answers the questions of relevant past history and relevant family history
Any information relevant to the patient’s current medical problem should be included in the HPI
Ensure a clear understanding of the chronology and progression of the symptoms leading to the CC
After exploring associated symptoms, inquire about risk factors relevant to the CC
When inquiring about pain and other symptoms, some people use OPQRST to remind them to ask about:
onset
precipitating factors
quality
radiation and relieving factors
severity
temporality
The interviwer should be able to compose a differential diagnosis at the end of an HPI
Past medical history (PMH)
The past medical history is a review of all medical events during the patient’s lifetime:
General state of health: «how has your health been in the past?»
Reproductive history: use of contraceptives, hormones
Past illnesses: medical, surgical and pediatric(measles, mumps, whooping cough, rheumatic fever, chikenpox, poli, and scarlet fever)
Injuries: type and date
Hospitalizations
Surgery: type of procedure, date, hospital, and surgeon’s name
Psychological/Psychiatric history
Immunization history
Allergies to medications, foods and other products (e.g. Latex) and sensitivities
Substance use:
Cigarette smoking: note the number of pack-years and the type of nicotine (i.e. cigarettes, cigars, chewing tobacco). Pack-year-the number of packs per day
Alcohol: type of alcohol consumed and weekly consumption amounts should be inquired about in a nonjudgmental manner. If alcohol abuse is supected, the CAGE questionaire should be asked.
Recreational drugs: document quantity and type of drug used
Diet: ask for a description of all food eaten the day before including all meals and snacks
Medications: including over the counter preparations, herbals, complimentary and alternative medications and remedies
Screening: pap smears (cervical and anal), mammography etc.
Family history (FH)
Health status of immediate family members, living and deceased
The age and health of all immediate family members and the age and cause of death of family members if applicable
Document in the form of a family tree or pedigree
Questions regarding the family history pertaining to the CC should be asked in the HPI.
Social history (SH)
Education
Occupation/employment (past and present)
Intimate relationships: home and family structure, marital status/primary relationship and other personal relationships, sexual relationships and orientation
Finances "where does your moeny come from?"
Religious beliefs (in relation to the perceptions of health and treatment)
Effect of the patient’s illness on his/her daily life
Patient attitude and outlook
Social and physical environments - explore for violence or abuse in all intimate relationships, other exposure to violence, living arrangements, neighbourhood, transportation
Personal health practices and coping skills
Ability and interest in accessing health services
Social support networks and care giving roles
Gender and gender specific stresses - coming out, gay bashing, sexual abuse, dysfunctional relationship
Culture
