Ask the patient to expand on the chief complaint or complaints. In particular, ask about anything that the patient was unclear about or that you don’t understand. Get specific numbers for things like how long the patient has had the symptoms or how much pain, on a scale of 0 to 10, the patient is experiencing. Record, as accurately as you can, what the patient tells you. Don’t add your interpretation to what you hear. [2] X Research source
The patient may not recognize that associated symptoms are related to the chief complaint and may not even view them as symptoms. You will have to interpret what you hear to complete this section of the medical history.
General constitution Skin and breasts Eyes, ears, nose, throat and mouth Cardiovascular system Respiratory system Gastrointestinal system Genitals and urinary system Musculoskeletal system Neurological or psychological symptoms Immunologic, lymphatic and endocrine system
Allergies and drug reactions Current medications, including over-the-counter drugs Current and past medical or psychiatric illnesses or conditions Past hospitalizations Immunization status Use of tobacco, alcohol or recreational drugs Reproductive status (if female), including date of last menstrual period, last gynecological exam, pregnancies and contraception method Information on children Family status, including whether the patient is married, who the patient lives with and other relationships. Include questions about the patient’s current sexual activity and history. Occupation, particularly if it includes exposure to hazardous materials
