Past History —Review past illnesses, surgical procedures and dates thereof, and all major injuries.
Family History—Obtain the health status of blood relatives, including their age if living and the cause of death if deceased.
Social History—The patient’s personal habits, sex life, emotional adjustments, and work and recreational habits are of importance.
Marital History—Health 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 patient’s complaint, not all questions are pertinent and should not be asked of the patient in every case,
Occupational History—Where 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 Weight—Determine 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 Nails—Check 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.
Head—Determine 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.
Eyes—Ask about disturbances in vision, lacrimation, itching, photophobia, and pain.
Ears-Determine the degree of deafness (if suspected), pain, discharge, vertigo, and tinnitus.
Nose—Note 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 Throat—Ask about pain and history of bleeding gums, sore throats, voice changes, and dysphagia (difficulty in swallowing), and look for indications of dental hygiene habits.
Neck—Determine if there are stiffness, swelling, pain and associated symptoms of lymph node enlargement, and limitation of motion.
Respiratory System—Check 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 System—Ask 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 (Raeynaud’s), heart murmurs, etc.
Gastrointestinal System—Ask 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 System—Ask 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