. Past History Review past illnesses,
surgical procedures and dates thereof, and all
. Family HistoryObtain the health status
of blood relatives, including their age if living and
the cause of death if deceased.
. Social HistoryThe patients personal
habits, sex life, emotional adjustments, and work
and recreational habits are of importance.
l Marital HistoryHealth of spouse, sex-
ual adjustment, number of children and their
health, and the emotional status of the marriage.
NOTE: Depending upon the circumstances and
the type of the patients complaint, not all
questions are pertinent and should not be asked
of the patient in every case,
. Occupational HistoryWhere the patient
works, what he or she does, who he or she works
for, how long in that position, health hazards
in that area, and recent changes in position
or authority may be important points to
. Include past environmental conditions
(i.e., foreign countries visited, areas of the
A comprehensive account of complaints
referable to each body system in logical sequence
from head to toe should be made a part of the
history. This review provides a thorough
evaluation of the past and present status of each
body system. It also permits the grouping of like
symptoms and provides a double check to
prevent omissions of significant data concerning
the present illness or injury. The following is
merely a suggested guideline to follow and should
not be interpreted as a hard and fast rule of
thumb. Again, each case is unique and should not
. Body WeightDetermine the average,
maximum, and least weight for the individual, and
check for loss or gain in weight and the time
interval between such loss or gain.
. Skin, Hair, and NailsCheck the texture
for dryness, sweating, discolorations, itching,
changes in temperature, dermatological conditions
and therapeutic efforts to control them, and
baldness and itching of the scalp.
. HeadDetermine if there are headaches,
their frequency, duration, and what time of day
they occur; be alert for and determine the presence
or absence of vertigo, lightheadedness, fainting,
and any signs of trauma.
. EyesAsk about disturbances in vision,
lacrimation, itching, photophobia, and pain.
l Ears-Determine the degree of deafness (if
suspected), pain, discharge, vertigo, and tinnitus.
. NoseNote any discharges or obstruc-
tions. Ask the patient if he or she is subject to
frequent colds or allergies and if there has been
any change in the sense of smell.
. Mouth and ThroatAsk about pain and
history of bleeding gums, sore throats, voice
changes, and dysphagia (difficulty in swallowing),
and look for indications of dental hygiene habits.
l NeckDetermine if there are stiffness,
swelling, pain and associated symptoms of lymph
node enlargement, and limitation of motion.
. Respiratory SystemCheck for com-
plaints of dyspnea, orthopnea, edema, cough
(productive or nonproductive, and if productive,
odor and color as well as amount of sputum),
pain, wheezing, palpitation, syncope, cyanosis,
hypertension, hoarseness, and stridor (harsh or
l Cardiovascular SystemAsk about
exertional dyspnea, paroxysmal nocturnal
dyspnea, chest pain, angina, myocardial infarc-
tion, claudication, orthopnea, varicosities,
phlebitis and circulatory problems in the
extremities, particularly with exposure to cold
(Raeynauds), heart murmurs, etc.
. Gastrointestinal SystemAsk about
changes in appetite, complaints of dysphagia,
pyrosis, indigestion, nausea, vomiting, blood in
stool or vomitus, flatulence, jaundice, pain,
changes in bowel habits, constipation, diarrhea,
l Genitourinary SystemAsk about fre-
quency of urination, including urgency, hesita-
tion, pain, blood, absence or diminishing amount,
pus, color, and dribbling or incontinence; and
check for past or present evidence of sexually
transmitted diseases (STD).