Past History Review past illnesses, surgical procedures and dates thereof, and all major injuries.
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.
Marital HistoryHealth of spouse, sexual 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 explore.
Include past environmental conditions (i.e., foreign countries visited, areas of the country visited).
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 be stereotyped.
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.
Ears-Determine the degree of deafness (if suspected), pain, discharge, vertigo, and tinnitus.
NoseNote any discharges or obstructions. 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.
NeckDetermine if there are stiffness, swelling, pain and associated symptoms of lymph node enlargement, and limitation of motion.
Respiratory SystemCheck for complaints 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 high-pitched respirations).
Cardiovascular SystemAsk about exertional dyspnea, paroxysmal nocturnal dyspnea, chest pain, angina, myocardial infarction, 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, and hemorrhoids.
Genitourinary SystemAsk about frequency of urination, including urgency, hesitation, pain, blood, absence or diminishing amount, pus, color, and dribbling or incontinence; and check for past or present evidence of sexually transmitted diseases (STD). 2-3