A practitioner typically asks questions to obtain the following
information about the patient:
Identification and demographics: name, age, height, weight.
The "chief complaint (CC)" - the major health problem or
concern, and its time course (e.g. chest pain for past 4 hours).
History of the present illness (HPI) - details about the
complaints, enumerated in the CC. (Also often called 'History of presenting
complaint' or HPC.)
Past Medical History (PMH) (including major illnesses, any
previous surgery/operations, any current ongoing illness, e.g. diabetes).
Review of systems (ROS) Systematic questioning about different
organ systems
Family diseases - especially those relevant to the patient's
chief complaint.
Childhood diseases - this is very important in pediatrics.
Social history (medicine) - including living arrangements,
occupation, marital status, number of children, drug use (including tobacco,
alcohol, other recreational drug use), recent foreign travel, and exposure to
environmental pathogens through recreational activities or pets.
Regular and acute medications (including those prescribed by
doctors, and others obtained over-the-counter or alternative medicine)
Allergies - to medications, food, latex, and other environmental
factors
Sexual history, obstetric/gynecological history, and so on, as
appropriate.
History-taking may be comprehensive history taking (a fixed and
extensive set of questions are asked, as practiced only by health care students
such as medical students, physician assistant students, or nurse practitioner
students) or iterative hypothesis testing (questions are limited and adapted to
rule in or out likely diagnoses based on information already obtained, as
practiced by busy clinicians). Computerized history-taking could be an integral
part of clinical decision support systems.
The Nurse takes Mrs. Wilson's medical history.
