What questions should be asked to a patient suspected of having lower iron levels?

History Questions for Suspected Iron Deficiency

When evaluating a patient for suspected iron deficiency, systematically inquire about blood loss sources, dietary intake, malabsorption conditions, and medication use—these four categories capture the vast majority of causes and guide appropriate investigation.

Blood Loss Assessment

Gastrointestinal Sources

• Ask about visible blood loss: melena (black, tarry stools), hematochezia (bright red blood per rectum), or hematemesis 1
• Screen for occult GI bleeding: change in bowel habits, abdominal pain, early satiety, or unintentional weight loss that may indicate GI malignancy 1
• Inquire about NSAID use: aspirin and non-aspirin NSAIDs are common causes of iron deficiency anemia through GI blood loss 1
• Ask about anticoagulant/antiplatelet therapy: these medications increase bleeding risk and should be documented 1

Menstrual and Gynecological Sources

• For premenopausal women: detailed menstrual history including cycle frequency, duration, and heaviness (number of pads/tampons per day, presence of clots) 1, 2
• Note: Blood loss from menstruation is the most common cause of iron deficiency in premenopausal women 1, 2

Other Blood Loss

• Ask about blood donation history: frequency and recency of donations 1
• Inquire about hematuria: visible or microscopic blood in urine 1

Dietary and Absorption History

Dietary Intake

• Obtain detailed dietary history: specifically assess iron-rich food consumption (red meat, poultry, fish, fortified cereals) 1
• Ask about dietary restrictions: vegetarian or vegan diet, which increases risk of iron deficiency 1
• Assess overall nutritional status: poor dietary intake is a common cause, particularly in developing regions 1

Malabsorption Conditions

• Screen for celiac disease symptoms: diarrhea, bloating, weight loss, or family history of celiac disease 1
  • Celiac disease is the most common malabsorption cause of iron deficiency in the UK 1
  • Approximately 5% of patients with iron deficiency anemia have celiac disease 1
• Ask about prior gastric surgery: gastrectomy or bariatric procedures impair iron absorption 1, 2
• Inquire about chronic diarrhea: may indicate inflammatory bowel disease or other malabsorptive conditions 1

Medication History

• Document all NSAIDs: including over-the-counter aspirin and ibuprofen use 1
• Review proton pump inhibitors: chronic use may impair iron absorption 2
• Note anticoagulants/antiplatelets: warfarin, DOACs, aspirin, clopidogrel 1

Associated Symptoms

Iron Deficiency-Specific Symptoms

• Ask about pica: craving for non-food items (ice, dirt, starch)—present in 40-50% of iron deficiency cases 2
• Screen for restless legs syndrome: uncomfortable leg sensations relieved by movement—present in 32-40% of cases 2
• Inquire about pruritus: generalized itching without rash may indicate iron deficiency 1
• Assess for fatigue: disproportionate tiredness, exercise intolerance, or dyspnea on exertion 2
• Ask about cognitive symptoms: difficulty concentrating, irritability, or depression 2

Red Flag Symptoms

• Screen for malignancy: unintentional weight loss, night sweats, fevers, or lymphadenopathy 1
• Assess urgency: men with Hb <12 g/dL and postmenopausal women with Hb <10 g/dL require more urgent investigation for serious disease 1

Chronic Disease Assessment

• Ask about chronic inflammatory conditions: inflammatory bowel disease (13-90% have iron deficiency), chronic kidney disease (24-85%), heart failure (37-61%), or cancer (18-82%) 2
• Inquire about chronic infections: these can cause functional iron deficiency 2

Family and Social History

• Obtain family history: inherited disorders of iron absorption, thalassemia, or hereditary hemorrhagic telangiectasia 1
• Assess pregnancy status: iron deficiency affects up to 84% of pregnant women in third trimester 2
• Document age and gender: critical for determining investigation urgency and approach 1

Key Clinical Pitfall

Remember that dual pathology occurs in 1-10% of patients—finding one source of bleeding (especially in older patients) does not exclude another, so maintain a high index of suspicion for multiple causes 1. Additionally, ferritin is an acute-phase reactant and may be falsely elevated in inflammatory conditions despite true iron deficiency 1.