History taking simplified...well kinda. There’s more scope to each domain but if you get the foundations right, your on to a good start! There’s many different ways to ask questions - I’ve only provided a few examples. Maintain good eye contact and sit at patient level. Always remember to WASH YOUR HANDS!
1. Introduce yourself - my name is..and I’m a third year medical student.
2. Obtain consent - I would like to ask you a few questions today about why you are here. Is that okay?
3. Confirm patient name, dob and age.
4. Presenting complaint - What problem has brought you into hospital?
5. History of PC - SOCRATES (site, onset, character, radiation, association, time, exacerbating/relieving, severity)
6. Past medical history - Do you have any medical conditions? Do you see the GP regularly for any reason? Have you had any operations in the past? JADE, TAB, MARCH
7. Family history - Any health problems in the family? Genetic/familial, siblings, consanguinity
8. Drug history - prescribed medication, over the counter
9. Social history - smoking (pack years), alcohol, recreational drugs, occupation, housing, children, social support, limitations in ability to carry out daily living activities, oversea travel.
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