How to Take a Medical History in Clinical Practice
Start by introducing yourself, establishing rapport in a comfortable environment, and systematically gather information beginning with the chief complaint using open-ended questions, followed by structured collection of past medical history, medications, allergies, family history, social history, and review of systems—all while maintaining active listening and documenting the patient's narrative in their own words. 1
Establishing the Right Environment and Initial Approach
Create rapport before diving into clinical questions. Position yourself with appropriate body language by orienting your lower body toward the patient and maintaining eye contact to demonstrate engagement 1. Introduce yourself and explain the purpose of the history-taking session to set clear expectations 1. Establish confidentiality parameters at the beginning, particularly important for adolescents and when discussing sensitive topics 1.
The Chief Complaint and History of Present Illness (HPI)
Begin with open-ended questions that allow the patient to tell their story without interruption. 1 This patient narrative drives the remainder of your examination and decision-making process 2. Document the patient's story in sufficient detail to accurately retell it, including the patient's own words when describing symptoms 1, 3.
For every presenting complaint, systematically document these seven elements 3:
- Onset and chronology: When symptoms began, their progression over time, and any patterns or changes in intensity 3
- Location: Where symptoms occur and if they radiate or move 3
- Quality: The patient's description of how symptoms feel (sharp, dull, burning, etc.) 3
- Severity: Use scales or ask how symptoms impact 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
Document associated symptoms that occur simultaneously. 3
Past Medical History
Obtain a thorough history of chronic conditions 1, 2:
- Cardiovascular: Myocardial infarction, arrhythmia/atrial fibrillation, coronary procedures (angioplasty, stent, bypass), pacemaker, congestive heart failure, angina, peripheral artery disease 1
- Cerebrovascular: Stroke (hemorrhagic or ischemic), transient ischemic attack, endarterectomy 1
- Other chronic conditions: Diabetes mellitus, hypertension, hyperlipidemia, renal disease, chronic viral hepatitis, peripheral neuropathy, gastrointestinal disease, lung disease, dementia, depression, liver disease, collagen vascular disease, musculoskeletal disease, malignancy 1, 2
Document dates of diagnosis, duration of chronic conditions, and prior negative tests. 2 Include past hospitalizations related to the current complaint 3 and relevant surgical procedures 3.
Medication History
An accurate medication history is an important element in patient safety and preventing prescription errors. 4, 5
Document comprehensively 1, 3:
- All prescription medications including names, dosages, frequencies, and duration of use 1
- Over-the-counter medications 1
- Methadone 1
- Dietary supplements and herbal remedies—some interact with prescription drugs 1
- Prior treatments for the current condition and their effectiveness 3
Document drug allergies and previous intolerances accurately. 4 Record the dose of the drug, the reaction suffered, its temporal relation to the drug, and susceptibility factors 4. Hypersensitivity reactions are often poorly documented or not explored in detail, which may lead to unnecessary avoidance of a drug. 5
Common pitfall: Pharmacists obtain better medication histories than physicians and reduce the rate and severity of medication errors during acute admissions 4. Consider involving pharmacy when available.
Family History
Obtain a three-generation family history focusing on first-degree relatives with relevant conditions. 1 Document history of stroke, vascular disease including myocardial infarction, dementia, and other neurological diseases in first-degree relatives 1. Record the age at which family members developed relevant conditions 3.
Social History
Document substance use including 1:
Record occupational history and environmental exposures (second-hand smoke, pesticides, medications) 1. Assess living conditions that might impact health 3 and identify support systems and resources available to the patient 3.
Review of Systems
Conduct a comprehensive symptom review covering all major organ systems 1:
- Constitutional symptoms
- HEENT (head/eyes/ears/nose/throat)
- Cardiovascular
- Respiratory
- Gastrointestinal
- Genitourinary
- Musculoskeletal
- Dermatologic
- Neurologic symptoms
Document pertinent negatives to demonstrate thoroughness. 1, 3 This includes important symptoms that are absent 3.
Communication Techniques During History Taking
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. Body language, facial expressions, and tone of voice provide additional clues influencing communicative effectiveness 6.
Population-Specific Considerations
- Adolescents: Consider seeing them alone for part of the interview and use developmentally appropriate approaches 1
- Elderly patients: Take extra time and be aware of higher risk for medication errors 1. Pay particular attention to functional status, cognitive function, and fall risk 3
- Patients with chronic conditions: Focus on changes from baseline and disease-specific symptoms 3
Documentation Best Practices
Use clear language and document the source of information. 1 Use macros and templates appropriately for standardized sections like review of systems 1, 2, but avoid "copy/paste" of entire notes without editing as this propagates errors, outdated information, and contradictory data. 1, 2
Include the patient's own words when documenting symptoms or concerns. 1 This preserves the authenticity of the patient narrative and can be clinically valuable.