What should be included in a comprehensive template for medical history gathering?

Comprehensive Medical History Gathering Template

A structured medical history template should systematically capture patient demographics, present illness details, past medical history, medications and allergies, family history, social history, review of systems, and physical examination findings, as this approach enables accurate diagnosis and treatment planning. 1, 2

Patient Demographics and Identifying Information

• Name, date of birth, gender, ethnicity/race to establish patient identity 2
• Primary language, years of education, occupation, living situation to understand patient context and communication needs 2
• Contact information and emergency contacts for care coordination 2

History of Present Illness (HPI)

Document the following seven cardinal features for every presenting complaint:

• Onset and chronology: When symptoms began, progression over time, patterns or changes in intensity 3
• Location: Where symptoms occur and whether they radiate or move 3
• Quality: Patient's description of how symptoms feel (sharp, dull, burning, pressure) 3
• Severity: Rate intensity using scales (0-10) or assess impact on daily activities 3
• Duration: How long symptoms last when they occur 3
• Context: Activities or situations when symptoms occur or worsen 3
• Modifying factors: What makes symptoms better or worse, including medications or interventions 3
• Associated symptoms: Other symptoms occurring simultaneously 3
• Pertinent negatives: Important symptoms that are absent 3

Past Medical History

Chronic conditions and diagnoses:

• All medical conditions including cardiovascular, cerebrovascular, pulmonary, renal, hepatic, endocrine, neurologic, psychiatric, and malignancies 2, 4
• Duration of chronic conditions, dates of diagnosis, and prior negative tests 4
• Disease-specific details: For HIV patients, document date of diagnosis, approximate date of infection, CD4 counts, viral loads, opportunistic infections 1, 4

Prior hospitalizations and procedures:

• All previous hospitalizations with dates, reasons, and outcomes 4
• Surgical history with dates, procedures, complications 4
• Blood product receipt with dates and indications 4

Infectious disease history:

• Sexually transmitted diseases: gonorrhea, chlamydia, pelvic inflammatory disease, chancroid, syphilis, herpes simplex virus, viral hepatitis, HPV 1
• HIV-related conditions: thrush, oral hairy leukoplakia, herpes zoster, cervical or anal dysplasia, Pneumocystis pneumonia, Kaposi sarcoma, lymphoma 1
• Vaccination history: childhood vaccinations, adult boosters, travel immunizations 4

Comorbidities and risk factors:

• Cardiovascular risk factors: coronary heart disease, dyslipidemia, diabetes mellitus, hypertension 1, 4
• Kidney disease and osteoporosis history 1, 4

Medications and Allergies

Current medications:

• All prescription drugs with names, dosages, frequencies, duration of use 1, 2, 3
• Over-the-counter medications, supplements, herbal remedies, methadone 1, 2, 3
• Prior medication use: specific drugs, duration of therapy, complications, side effects, drug resistance, adherence 1, 4
• For HIV patients: prior antiretroviral therapy including prevention for mother-to-child transmission or pre-/post-exposure prophylaxis 1

Allergies and adverse reactions:

• All drug allergies with dates and types of reactions (rash, anaphylaxis, GI upset) 4, 3
• Food and environmental allergies 4

Family Medical History

Three-generation family history focusing on:

• First-degree relatives (parents, siblings, children) with relevant conditions 2, 4
• Early coronary heart disease: myocardial infarction in male relatives before age 55 or female relatives before age 65 1
• Hereditary conditions: malignancies, neurologic diseases, osteoporosis, atherosclerotic disease, hypertension, diabetes mellitus, hyperlipidemia 1, 2
• Age at which family members developed relevant conditions 3

Social History

Substance use:

• Tobacco use: type, amount, duration, pack-years 4, 3
• Alcohol use: type, amount, frequency, CAGE screening 4, 3
• Recreational drug use: types, routes, frequency 4, 3

Occupational and environmental:

• Employment history and occupational exposures 4, 3
• Living conditions that might impact health 3
• Travel history: birthplace, residence, recent travel 4

Psychosocial factors:

• Support systems and resources available to the patient 3
• Sexual history: number of partners, gender of partners, safe sex practices 1
• History of sexual or physical abuse, childhood sexual abuse 1

Psychiatric History

Mental health screening:

• Depression screening: changes in mood, libido, sleeping patterns, appetite, concentration, memory 1
• Anxiety and posttraumatic stress disorder symptoms 1
• Suicidal ideation assessment 1
• Prior psychiatric hospitalizations and treatments 1
• Domestic violence screening 1

Review of Systems

Comprehensive symptom review with HIV-specific emphasis:

• Constitutional: fever, night sweats, weight loss (compare current weight with baseline) 1
• HEENT: headaches, visual changes, oral thrush or ulceration 1
• Cardiovascular: chest pain, palpitations, orthopnea, paroxysmal nocturnal dyspnea 1
• Respiratory: cough, dyspnea, wheezing 1
• Gastrointestinal: swallowing difficulties, nausea, vomiting, abdominal pain, diarrhea 1
• Genitourinary: urinary symptoms, anogenital symptoms 1
• Musculoskeletal: joint pain, muscle weakness 1
• Dermatologic: skin rashes or lesions 1
• Neurologic: changes in neurological function or mental status 1
• For women: menstrual history, gynecologic and obstetric history, plans for pregnancy, birth control practices, mammogram history 4

Physical Examination

Vital signs and measurements:

• Temperature, blood pressure, heart rate, respiratory rate, oxygen saturation 2
• Height, weight, BMI 1, 2
• Head circumference in children aged <3 years plotted against standard growth curves 1

Targeted examination based on presenting complaint:

• General appearance and mental status 2
• Body habitus: assess for wasting, obesity, lipohypertrophy (dorsocervical fat pad, gynecomastia, visceral abdominal fat), lipoatrophy (loss of subcutaneous fat in face, extremities, buttocks) 1
• Volume status: jugular venous pressure, peripheral edema 2
• Lymph nodes: focal or rapidly progressive lymphadenopathy may require biopsy 1
• Cardiovascular and pulmonary examination including peripheral vascular disease assessment 1
• Ophthalmologic examination: dilated examination for patients with CD4 count <50 cells/µL 1
• Neurologic examination: assess for neurocognitive disorders, dementia, focal neuropathies 1

Documentation Best Practices

• Document pertinent negatives to demonstrate thoroughness 4, 3
• Use clear language understandable by other providers 4, 3
• Document source of information (patient, family member, prior records) 4
• Assess patient's literacy and primary language 4

Common Pitfalls to Avoid

• Failing to document allergies and adverse medication reactions leads to preventable adverse events 4
• Incomplete vaccination records result in missed opportunities for preventive care 4
• Overlooking family history misses genetic risk factors for disease 4
• Inadequate social history fails to identify substance abuse, domestic violence, or psychosocial stressors that impact health 1