How to Take a Patient's Medical History

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Taking a patient's medical history is a necessary part of working in hospitals, health centers, doctors' offices or other health care centers. It involves asking the patient about her reason for the visit, and then asking about her health history, as well as the histories of her immediate family members. It isn't difficult, but, depending on the patient, it can be time consuming. Do your best to keep the patient focused, and take good notes as they speak.

  • Ask about the patient's current problem, or the reason for the visit. This includes asking about the symptoms, how long the problem has existed, and if it has changed at all (gotten worse or better) in that time. You also need to ask if this particular complaint, or something similar, has been a problem before.

  • Find out which medications, if any, the patient is currently taking. Also ask about any recently taken medications. Sometimes the side effects of a particular medication can cause symptoms that require the patient to seek care. At this point, you will also probably ask for the patient's weight and height, or even measure them yourself if needed.

  • Develop a medical history for the patient. What medications are they allergic to? What serious illnesses or injuries have they had in the past? This is essential information. If a patient is allergic to penicillin, for example, there are a range of medications that cannot be given. Taking the history of previous medical issues may allow you to see any connections between the conditions.

  • Inquire about the patient's family medical history. This usually involves asking about the current and previous health issues of siblings, parents, aunts and uncles, and grandparents. As many conditions are genetic, knowing that there is a family history of diabetes, heart disease or some other health issue may be relevant to the patient's current complaint.

  • Find out the patient's social history. Does he or she smoke, drink or do drugs? Have they done any of these things in the past? Depending on the reason for the visit, you may also need to ask about the patient's sexual history or their fitness and nutrition habits. This is also when you will ask about depression, anxiety and their current living situation and support.

  • Complete a systems review. Start at the head, and work your way down. Ask about any skin conditions, cramping, aches and pains, dizziness or any other problems the patient might have that they haven't mentioned. Patients won't always tell you everything, because they may think a symptom is unrelated or unimportant. When you take a patient's medical history, you need to find out about these potential complaints, and put them into the notes. They may be essential to the diagnosis.

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