What are the steps to take a good medical history?

How to Take a Good Medical History

Begin by establishing rapport in a comfortable environment, then systematically gather information starting with the chief complaint using open-ended questions, followed by structured collection of past medical history, medications, family history, social history, and review of systems—all while maintaining active listening and documenting the patient's narrative in their own words. 1

Creating the Right Environment and Establishing Rapport

• Introduce yourself and explain the purpose of the history-taking session to set clear expectations with the patient 1
• Position yourself with appropriate body language by orienting your lower body toward the patient and maintaining eye contact to demonstrate engagement 1
• Establish confidentiality parameters at the beginning, particularly important for adolescents and when discussing sensitive topics 1
• Create a comfortable, non-threatening environment where patients feel safe sharing sensitive information 1

Systematic Approach to History Collection

Chief Complaint and History of Present Illness

• Start with open-ended questions allowing the patient to tell their story in their own words without interruption 1, 2
• Document the patient's narrative in sufficient detail to accurately retell their story, including the patient's own words when describing symptoms 1, 3
• For every presenting complaint, systematically document: onset and chronology, location, quality, severity, duration, context, and modifying factors 2
• Ask about time of day when symptoms worsen (morning worsening suggests certain conditions like blepharitis, while evening worsening suggests others like aqueous deficient dry eye) 4

Demographics and Patient Identification

• Record name, date of birth, gender, race/ethnicity including birthplace and parents' places of origin 4, 2
• Document primary language, years of education, occupation, literacy level, and living situation 4, 2
• Include marital status, handedness, and contact person information 4

Past Medical History

• Obtain a thorough cardiovascular history including myocardial infarction, arrhythmia/atrial fibrillation, coronary procedures (angioplasty, stent, bypass), pacemaker, congestive heart failure, angina, and peripheral artery disease 4
• Document cerebrovascular disease including stroke (hemorrhagic or ischemic), transient ischemic attack, and endarterectomy 4
• Ask about chronic conditions: diabetes mellitus, hypertension, hyperlipidemia, renal disease, chronic viral hepatitis, peripheral neuropathy, gastrointestinal disease 4
• Include history of surgeries and whether cognitive difficulties arose post-operatively 4
• Document infectious disease history including tuberculosis exposure with tuberculin skin test results, sexually transmitted diseases, and chronic infections 4
• For specific populations, gather disease-specific details (e.g., for HIV patients: date of diagnosis, approximate date of infection, CD4 counts, viral loads, prior antiretroviral therapy with responses and resistance patterns) 4, 2
• Ask about immunization status including tetanus, pneumococcal, hepatitis A and B, influenza vaccines with dates 4, 3
• Document travel history and places of residence, particularly areas endemic for specific infections (Ohio/Mississippi River valleys for histoplasmosis, southwestern deserts for coccidioidomycosis) 4

Medication History

• Document all prescription medications including names, dosages, frequencies, and duration of use 2
• Include over-the-counter medications, methadone, dietary supplements, and herbal remedies—some interact with prescription drugs 4, 2
• For patients on chronic therapy, document prior medications, duration of treatment, reasons for changes, drug toxicities, and adherence 4, 2
• Record all drug allergies and hypersensitivity reactions, including specific reactions to sulfonamides and other drug classes 4

Family History

• Obtain a three-generation family history focusing on first-degree relatives with relevant conditions 2
• Document history of stroke, vascular disease including myocardial infarction, dementia, and other neurological diseases in first-degree relatives 4
• Record age at death and age of disease events (e.g., stroke) for family members 4
• Include early coronary heart disease and hereditary conditions 2

Social History

• Document substance use including tobacco, alcohol, heroin, marijuana, cocaine, and other recreational drugs 4, 2
• Record occupational history and environmental exposures (second-hand smoke, pesticides, medications) 4, 2
• Include diet, lifestyle factors, and living situation/level of independence 4
• Assess recent stressors or significant life events and their impact on daily life, work, and relationships 1
• For women, document menopause status and contraceptive use 4

Review of Systems

• Conduct a comprehensive symptom review covering: constitutional, HEENT (head/eyes/ears/nose/throat), cardiovascular, respiratory, gastrointestinal, genitourinary, musculoskeletal, dermatologic, and neurologic symptoms 2
• Document pertinent negatives to demonstrate thoroughness 2

Special Communication Techniques

• Practice active listening by maintaining eye contact, nodding, and providing verbal acknowledgment 1
• Use motivational interviewing techniques for sensitive topics or when addressing health behavior change 1
• Avoid rushing through the history—allow sufficient time for the patient to tell their story 1
• Consider using an informant when relevant, documenting their relationship to the patient, amount and type of contact, and their demographics 4

Population-Specific Considerations

• For adolescents: Consider seeing them alone for part of the interview and use developmentally appropriate approaches 1
• For elderly patients: Take extra time and be aware of higher risk for medication errors 1
• For patients with intellectual disabilities: Obtain a historical description of baseline functioning from a family member or caregiver who knows the individual well, then compare current functioning to baseline 4

Documentation Best Practices

• Use clear language and document the source of information 2
• Use macros and templates appropriately for standardized sections like review of systems, but avoid "copy/paste" of entire notes without editing as this propagates errors 3
• Include the patient's own words when documenting symptoms or concerns 1, 3

Common Pitfalls to Avoid

• Do not focus exclusively on biomedical aspects while ignoring psychosocial factors 1
• Avoid overreliance on templates or electronic health records at the expense of patient engagement 1
• Do not rush through the history or interrupt the patient's narrative prematurely 1