What should be included in a complete Infectious Disease (IDS) history?

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Last updated: November 22, 2025 • View editorial policy

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Complete Infectious Disease History

A comprehensive infectious disease history must include detailed documentation of HIV diagnosis and treatment history, past opportunistic infections and HIV-related complications, sexually transmitted disease history, tuberculosis screening, immunization status, complete medication and allergy history, social and sexual practices, and healthcare maintenance records. 1

HIV-Specific History Components

HIV Diagnosis and Duration

  • Document how, where, when, and why HIV diagnosis was made 1
  • Obtain dates of prior negative HIV tests to estimate duration of infection 1
  • Ask about symptoms of acute retroviral syndrome at time of infection 1
  • Inquire about lowest CD4 cell count and highest viral load ever recorded 1

HIV Medication History

  • Document all prior antiretroviral therapy including specific drug combinations 1
  • Record duration of each treatment regimen and reasons for changes 1
  • Obtain CD4 cell count and viral load response to each regimen 1
  • Document complications, side effects, and adherence patterns 1
  • Ask about prior drug resistance test results 1
  • Inquire about pre-exposure prophylaxis (PrEP) or post-exposure prophylaxis (PEP) use 1
  • Document prevention of mother-to-child transmission medications if applicable 1

HIV-Related Complications and Comorbidities

Opportunistic Infections and HIV-Related Conditions

  • Thrush and oral hairy leukoplakia 1
  • Herpes zoster (shingles) 1
  • Pneumocystis pneumonia 1
  • Other opportunistic infections 1
  • Kaposi sarcoma and lymphoma 1
  • Cervical or anal cancer or dysplasia 1
  • Peripheral neuropathy 1
  • Hematologic abnormalities: anemia, neutropenia, thrombocytopenia 1
  • Neurocognitive impairment 1

Cardiovascular and Metabolic Comorbidities

  • History of and risk factors for coronary heart disease 1
  • Dyslipidemia 1
  • Diabetes mellitus 1
  • Kidney disease 1
  • Osteoporosis 1

Psychiatric and Mental Health History

  • Treatment for or symptoms of depression 1
  • Anxiety disorders 1
  • Suicidal ideation 1
  • Post-traumatic stress disorder 1
  • Psychiatric hospitalizations 1

Sexually Transmitted Disease History

Document complete history with treatment outcomes for: 1

  • Gonorrhea
  • Chlamydia
  • Pelvic inflammatory disease
  • Chancroid
  • Syphilis
  • Herpes simplex virus
  • Viral hepatitis (A, B, C)
  • Human papillomavirus (HPV)
  • Trichomoniasis

Gender-Specific History

For Women

  • Complete gynecologic and obstetric history 1
  • Plans for future pregnancy 1
  • Birth control practices 1
  • Last Pap test and any history of abnormal results 1
  • Menstrual history 1
  • Mammogram history if applicable 1

For Pediatric Patients

  • Maternal obstetric and birth history 1
  • Exposure to perinatal antiretrovirals 1
  • Exposure to infectious diseases 1
  • Growth and development milestones 1

Healthcare Maintenance and Screening

Tuberculosis

  • History of tuberculosis disease or exposure 1
  • Last tuberculin skin test or interferon-gamma release assay 1
  • Treatment for latent tuberculosis if applicable 1

Immunization History

Document dates for: 1

  • Childhood vaccinations
  • Tetanus-diphtheria (dT) or tetanus-diphtheria-pertussis (Tdap)
  • Hepatitis A and B vaccines
  • Human papillomavirus (HPV) vaccine
  • Influenza vaccine (annual)
  • Meningococcal vaccine
  • Pneumococcal vaccine
  • Varicella zoster vaccine
  • Travel-related vaccinations

Other Preventive Care

  • Last eye examination including dilated funduscopic exam 1
  • Last dental visit 1

Past Medical History

  • All hospitalizations not mentioned above 1
  • Surgical procedures 1
  • Blood product receipt 1

Family Medical History

  • Diabetes 1
  • Early heart disease 1
  • Hypertension 1
  • Cancer 1

Social History

Demographics and Identity

  • Race and ethnicity 1
  • Sex and sexual identity 1
  • Patient birthplace, residence, and travel history 1

Health-Related Behaviors

  • Tobacco use 1
  • Alcohol consumption 1
  • Recreational drug use (marijuana, cocaine, methamphetamine, ecstasy, ketamine) 1

Transmission Risk Assessment

  • Sexual contacts (men, women, or both) 1
  • Types of sexual activity and exposure sites 1
  • Condom use patterns 1
  • History of injection drug use 1
  • Shared needles or syringes 1
  • History of blood transfusion or receipt of blood products, especially 1975-1985 1
  • Artificial insemination by unidentified donor 1
  • History of organ transplant or semen donation 1

Relationship and Support

  • Marital/relationship status 1
  • Partner's health and HIV status 1
  • Partner's access to healthcare and HIV testing 1
  • Disclosure of HIV status to partner(s) 1
  • Social support systems and participation in support groups 1
  • For minors, review legal guardianship 1

Occupational and Environmental

  • Employment history 1
  • Pets 1
  • Diet and exercise patterns 1

Medication and Allergy History

Current Medications

  • All prescription medications 1
  • Over-the-counter medications 1
  • Complementary or alternative therapies 1
  • Herbal supplements 1
  • Methadone if applicable 1

Allergies

  • Document dates of allergic reactions 1
  • Specify types of reactions (rash, anaphylaxis, etc.) 1
  • Pay particular attention to hypersensitivity reactions to sulfonamides, non-nucleoside reverse-transcriptase inhibitors, and abacavir 1

Critical Pitfalls to Avoid

Incomplete antiretroviral history is a common error—always obtain medical records from previous providers to verify medication regimens, resistance patterns, and treatment responses rather than relying solely on patient recall. 1

Failure to document sexual practices in detail compromises risk assessment and partner notification—use open, non-judgmental language to elicit accurate information about specific sexual activities and exposure sites. 1

Overlooking travel and residence history may miss endemic exposures to histoplasmosis (Ohio and Mississippi River valleys) or coccidioidomycosis (southwestern deserts) that can reactivate even after relocation. 1

References

1
Guideline

Guideline Directed Topic Overview

Dr.Oracle Medical Advisory Board & Editors, 2025

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Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

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