Essential Questions for a Patient's First Visit to a Primary Care Physician
The first visit to a primary care physician should include a comprehensive assessment of the patient's health history, current concerns, medications, social determinants, and preventive health needs through structured questioning.
Initial Assessment and Rapport Building
Opening the Visit
- Begin with open-ended questions to establish rapport 1:
- "What brings you in today?" or "What can I do for you today?"
- "What health concerns would you like to discuss?"
- Ask about patient expectations: "What are you hoping to accomplish during our visit today?" 2
- Use agenda setting to identify all concerns: "Are there other issues you'd like to address today?" 3
Chief Complaint and Present Illness
- For each concern, explore:
- Onset, duration, and progression of symptoms
- Severity and impact on daily activities
- Aggravating and alleviating factors
- Prior treatments attempted and their effectiveness 2
- For urgent symptoms, assess severity and need for immediate intervention 4
Comprehensive Health History
Past Medical History
- Ask about chronic conditions, hospitalizations, surgeries, and significant illnesses
- Inquire about specific conditions requiring ongoing management:
- Cardiovascular disease (hypertension, coronary artery disease)
- Respiratory conditions (asthma, COPD)
- Endocrine disorders (diabetes, thyroid disease)
- Mental health conditions (depression, anxiety) 2
Medication and Allergy Assessment
- Document all current medications including:
- Prescription medications with dosages and schedules
- Over-the-counter medications
- Dietary supplements and herbal remedies
- Methadone or other substance treatment medications 2
- Record all medication allergies and the nature of reactions
- Document other allergies (environmental, food) 2
Preventive Health and Immunizations
- Review immunization status and update as needed
- Document age-appropriate cancer screenings (breast, colorectal, cervical, prostate)
- Ask about last physical examination, dental visit, and eye examination 2
Social and Family History
Social History
- Assess tobacco, alcohol, and substance use 2:
- For tobacco: type, amount, duration, and quit attempts
- For alcohol: frequency, quantity, and any concerns about consumption
- For substances: types used, frequency, route of administration, and treatment history
- Sexual history (in a non-judgmental manner):
- Sexual activity, partners, and practices
- Contraception methods
- STI history and prevention 2
- Occupational history and exposures
- Exercise habits and dietary patterns 2
Family History
- Document family history of:
- Cardiovascular disease (especially premature)
- Cancer (types and age of onset)
- Diabetes, hypertension, and hyperlipidemia
- Mental health conditions
- Other heritable conditions 2
Psychosocial Assessment
Mental Health Screening
- Screen for depression and anxiety 2
- Assess stress levels and coping mechanisms
- Ask about sleep patterns and any difficulties 2
Social Determinants of Health
- Housing situation and stability
- Food security
- Transportation access
- Financial concerns affecting healthcare
- Social support systems 2
Quality of Life Assessment
- Ask open-ended questions about life impact: "How do your health issues interfere with your ability to do what you want to do in your daily life?" 2
- Assess for unmet needs that may require additional support 2
Shared Decision Making and Plan Development
Patient Preferences and Goals
- Ask about treatment preferences: "What are your thoughts about how we should approach your health concerns?" 5
- Determine health goals: "What health goals are most important to you?" 2
- Assess health literacy and information needs: "What questions do you have about your health?" 2
Closing the Visit
- Summarize findings and recommendations
- Verify understanding using teach-back: "To make sure I explained things clearly, could you tell me your understanding of our plan?" 2
- Establish follow-up plans and expectations 6
Special Considerations
Pediatric Patients
- Include both child and parent perspectives
- Assess developmental milestones
- Review growth patterns
- Evaluate school performance and social adjustment 2
Elderly Patients
- Assess functional status and independence in activities of daily living
- Screen for cognitive impairment
- Evaluate fall risk
- Review advance directives 2
Patients with Chronic Conditions
- Ask about disease-specific symptoms and management
- Review self-monitoring practices
- Assess adherence to treatment plans
- Identify barriers to care 2
By systematically addressing these areas during a first visit, primary care physicians can establish a comprehensive baseline assessment, identify immediate concerns requiring intervention, and develop a foundation for an ongoing therapeutic relationship.