What are the essential history questions to assess a symptom's onset, frequency, duration, triggers, relieving factors, associated features, and relevant past medical history?

Essential History Questions for Symptom Assessment

When evaluating any symptom, systematically document onset, frequency, duration, precipitating factors, relieving factors, associated symptoms, and relevant past medical history to establish diagnostic criteria and guide management decisions.

Core Temporal Characteristics

Onset

• Document the exact age or date when symptoms first began, as onset timing is essential for applying diagnostic criteria and distinguishing acute from chronic conditions 1.
• Determine whether onset was sudden (instantaneous) or gradual (building over minutes to hours), because sudden onset suggests vascular events like aortic dissection or pulmonary embolism, while gradual onset over minutes characterizes conditions like angina 1.
• Identify any related or resolved symptoms from infancy or childhood that may inform current diagnosis 1.
• Ask specifically about the timing of symptom onset relative to presentation (e.g., hours, days, weeks) to assess urgency 1.

Frequency and Pattern

• Establish whether symptoms are continual, episodic, or recurrent, as this distinction separates conditions like chronic migraine (≥15 headache days/month) from episodic migraine 1.
• Document the number of episodes (e.g., migraine requires ≥5 attacks fulfilling diagnostic criteria) 1.
• Determine if there is a seasonal, perennial, or combined pattern, particularly for conditions like allergic rhinitis 1.
• Ask about timing after exposure to triggers (immediate versus delayed onset) to identify cause-and-effect relationships 1.

Duration

• Record the duration of each individual episode (e.g., migraine attacks last 4-72 hours untreated; aura symptoms last 5-60 minutes) 1.
• Distinguish fleeting symptoms (seconds) from sustained symptoms (minutes to hours), because fleeting chest pain lasting only seconds is unlikely to be cardiac ischemia 1.
• Document total duration of the condition (e.g., chronic migraine requires >3 months; medication-overuse headache requires ≥3 months of overuse) 1.

Symptom Characteristics

Quality and Severity

• Ask patients to describe symptoms in their own words first, then provide specific examples, because terms like "memory loss" or "confusion" may mean different things to patients versus clinicians 1.
• Encourage elaboration with concrete examples rather than accepting vague descriptors 1.
• Document pain quality using specific descriptors: pressure, squeezing, heaviness, tightness for cardiac pain; sharp, stabbing, pleuritic for non-cardiac causes 1, 2.
• Rate severity on a standardized scale (mild, moderate, severe) and assess both past and present severity 1.
• Determine if symptoms are unilateral or bilateral, as unilateral pulsating headache suggests migraine 1.

Location and Radiation

• Record the exact anatomical location of symptoms 1.
• Document radiation patterns: cardiac pain radiates to left arm, neck, jaw; aortic dissection radiates to back; pain below the umbilicus is unlikely cardiac 1, 2.
• Note if pain can be localized to a very limited area, which makes ischemic heart disease unlikely 1.

Precipitating and Aggravating Factors

• Identify specific triggers that precipitate or worsen symptoms, including allergens, irritants, hormonal influences, exercise, eating, medications, and weather changes 1.
• Document physical exertion or emotional stress as triggers, which are common for anginal symptoms 1.
• Ask about positional changes: symptoms worsening supine suggest pericarditis; symptoms with lying down after prolonged sitting/standing may trigger myocardial infarction 1, 3.
• Determine if symptoms worsen with inspiration, coughing, or movement, indicating pleuritic or musculoskeletal origin 1, 4.
• Assess relationship to geographical location or specific activities (e.g., home versus work, dusting, raking leaves) 1.
• Note aggravation by routine physical activity, which is characteristic of migraine 1.

Relieving Factors

• Document what makes symptoms better, including rest, position changes, medications, or other interventions 1.
• Specifically ask about response to previous treatments, including pharmacologic success or failure 1.
• Note that nitroglycerin relief is NOT diagnostic of cardiac ischemia and should not be used as a diagnostic criterion, as esophageal spasm also responds 1, 2, 4.
• Record if symptoms improve with specific positions (e.g., pericarditis improves leaning forward) 4.

Associated Symptoms

Systematic Review by System

• For headache: Ask about photophobia, phonophobia, nausea, vomiting, aura symptoms (visual, hemisensory disturbances) 1.
• For chest pain: Document diaphoresis, dyspnea, palpitations, lightheadedness, presyncope, syncope, upper abdominal pain, nausea, vomiting 1, 2.
• For rhinitis: Assess nasal congestion, sneezing, rhinorrhea, throat symptoms (soreness, dryness, post-nasal drip), cough, ocular symptoms (redness, tearing, itching), voice changes, snoring, sinus pain/pressure, ear symptoms, itching of nose/ears/throat 1.
• For cognitive symptoms: Evaluate mood/behavioral changes, daily function impairment, sleep disturbances 1.

Timing of Associated Symptoms

• Determine if associated symptoms occur simultaneously, precede, or follow the primary symptom 1.
• For migraine with aura, document that aura symptoms are fully reversible, spread gradually over ≥5 minutes, last 5-60 minutes, and are followed by headache within 60 minutes 1.

Past Medical and Medication History

Relevant Medical History

• Obtain a complete past medical history, focusing on conditions relevant to the presenting symptom 1.
• Document family history, particularly for conditions with genetic components like migraine (higher prevalence among first-degree relatives) 1.
• Ask about onset at or around puberty for conditions like migraine 1.
• Record history of similar episodes and any prior diagnoses 1.

Medication History

• Document all current and past medications, including acute and preventive treatments 1.
• Specifically assess for medication overuse: non-opioid analgesics on ≥15 days/month for ≥3 months OR any other acute medication on ≥10 days/month for ≥3 months 1.
• Record response to previous medications to guide future treatment 1.

Functional Impact and Quality of Life

• Assess the effect on work or school performance, sleep quality, and overall quality of life 1.
• Document disability caused by symptoms using validated instruments when available 1.
• Determine if symptoms prevent routine physical activity 1.

Red Flags and High-Risk Features

• Screen for alarm features requiring urgent evaluation: thunderclap headache, new headache after age 50, progressively worsening symptoms, fever, abnormal neurological findings 5.
• For chest pain, identify high-risk features: age >75 years with accompanying symptoms, hemodynamic instability, prolonged ongoing rest pain, associated diaphoresis/dyspnea/syncope 1, 2.
• Document any sudden, severe, or "worst ever" symptoms that suggest life-threatening causes 1, 2, 4.

Structured Documentation Approach

• Use validated questionnaires and structured interviews to ensure systematic application of diagnostic criteria 1.
• Maintain headache diaries or symptom calendars to record temporal patterns, frequency, and related events 1.
• Interview both patient and informants separately when appropriate to capture different perspectives, particularly for cognitive or behavioral symptoms 1.
• Document the profile of characteristics, intensity, temporal course, and impact as a critical element of history-taking 1.