Medical history taking

Standard history taking

• Name
• Address
• Date of birth
• Date of admission
• Presenting complaint
• History of presenting complaint
• Previous medical history
• Systems enquiry
• Drug history and allergy
• Family history
• Social history
• Conclusion/summary

General questions to ask the patient:

• Tell me what seems to be the problem.
• How long have you been unwell?
• When did the symtoms start?
• Not What brought you here?

History of presenting complaint

If the history of the presenting complaint includes pain, ask about it using the
mnemonic SOCRATES
• Site - where exactly is this pain?
• Onset - when did the pain start, did it start suddenly or gradually?
• Character - describe the pain - sharp? knife-like? burning?
• Radiation - does the pain spread anywhere?
• Associations - is the pain accompanied by any other features?
• Timing - does the pain vary in intensity during the day?

Drug history and allergies
• What drugs, homoeopathic and herbal medicines and/or health foods
do you take? - and in what dose?
• Do you have any allergies?

Family history
• Are your father, mother, brothers, sisters alive? - If they have died, at
what age did he/she/they die? What did he/she/they die of?
• Do they have any current illnesses?
• Do any illnesses run in your family?

Social history
• Who is at home with you?
• Are you single, married, widowed or divorced?
• Is your partner healthy?
• How many children have you got?
• Are your children healthy?
• What is your occupation?
• Do you have any financial worries?
• Do you smoke? - If so, how may per day/week?
• Have you ever smoked? - Why did you give up?
• Do you drink alcohol? - If so, how many units per day/week?
• Have you been abroad? - If so, where?
• Do you have pets?
• If mobility is a problem: What is your home like? Do you have to
manage stairs? What facilities have you got?