• Problem or symptom: reason for visit

• Duration of problem

• Other concerns: secondary issues, fears, concerns, what made patient seek care

• Always consider why this particular problem may be affecting this particular patient at this time. Why did this patient succumb to a risk or an exposure when others similarly exposed did not?

• Chronologic ordering: sequence of events patient has experienced

• State of health just before onset of present problem

• Complete description of first symptom: time and date of onset, location, movement

• Possible exposure to infection or toxic agents

• If symptoms are intermittent, describe typical attack: onset, duration, symptoms, variations, inciting factors, exacerbating factors, relieving factors

• Impact of illness: on lifestyle, on ability to function; limitations imposed by illness

• “Stability” of problem: intensity, variations, improvement, worsening, staying the same

• Immediate reason for seeking attention, particularly for long-standing problem

• Review of appropriate system when there is a disturbance of a particular organ or system

• Medications: current and recent, dosage of prescriptions, nonprescription medications

• Use of complementary or alternative therapies and medications; home remedies

• At conclusion, review of chronology of events for each problem: patient’s confirmations and corrections

• Hospitalizations and/or surgery (including outpatient surgery): dates, hospital, diagnosis, complications, injuries, disabilities

• Major childhood illnesses: measles, mumps, pertussis, varicella, scarlet fever, rheumatic fever

• Major adult illnesses: tuberculosis, hepatitis, diabetes mellitus, hypertension, myocardial infarction, tropical or parasitic diseases, other infections

• Serious injuries: traumatic brain injury, liver laceration, spinal injury, fractures

• Immunizations: polio, diphtheria, pertussis, tetanus toxoid, hepatitis B, measles, mumps, rubella, Haemophilus influenzae, varicella, influenza, hepatitis A, meningococcal, human papillomavirus, pneumococcal, zoster, cholera, typhus, typhoid, anthrax, smallpox, bacille Calmette-Guérin, last purified protein derivative (PPD) or other skin tests, unusual reaction to immunizations

• Medications: past, current, and recent medications (dosage, nonprescription medications, vitamins); complementary and herbal therapies

• Allergies: drugs, foods, environmental allergens along with the allergic reaction (e.g., rash, anaphylaxis)

• Transfusions: reason, date, and number of units transfused; reaction, if any

• Mental health: mood disorders, psychiatric therapy or medications

• Recent laboratory tests: glucose, cholesterol, Pap smear/human papillomavirus (HPV), HIV, mammogram, colonoscopy or fecal occult blood test, prostate-specific antigen

• Relatives with similar illness

• Immediate family: ethnicity, health, cause of and age at death

• History of disease: heart disease, high blood pressure, hypercholesterolemia, cancer, tuberculosis, stroke, epilepsy, diabetes, gout, kidney disease, thyroid disease, asthma and other allergic states, forms of arthritis, blood diseases, sexually transmitted diseases, other familial diseases

• Spouse and children: age, health

• Hereditary disease: history of grandparents, aunts, uncles, siblings, cousins; consanguinity

• Cultural background and practices, birthplace, where raised, home environment as youth, education, position in family, marital status or same-sex partner, general life satisfaction, hobbies, interests, sources of stress, religious preference (religious or cultural proscriptions concerning medical care)

• Home environment: number of individuals in household, pets, economic situation

• Occupation: usual work and present work if different, list of job changes, work conditions and hours, physical or mental strain, duration of employment; present and past exposure to heat and cold, industrial toxins; protective devices required or used; military service

• Environment: home, school, work, structural barriers if physically disabled, community services utilized; travel and other exposure to contagious diseases, residence in tropics; water and milk supply, other sources of infection when applicable

• Current health habits and/or risk factors: exercise; smoking (pack years: packs per day × duration); salt intake; obesity/weight control; diet; alcohol intake: (amount/ day), duration; CAGE or TACE question responses (see Appendix on special histories); illicit drugs and methods (e.g., injection, ingestion, sniffing, smoking, or use of shared needles)

• Exposure to chemicals, toxins, poisons, asbestos, or radioactive material at home or work and duration; caffeine use (cups/glasses/day)

• Sexual activity: contraceptive or barrier protection method used; past sexually transmitted infection; treatment

• Screen for domestic or partner violence: see Appendix on special histories

• Complementary and alternative health and medical systems: history and current use

• Religious preference: religious proscriptions concerning medical care

• Concerns about cost of care, health care coverage

• General constitutional symptoms: fever, chills, malaise, easily fatigued, night sweats, weight (average, preferred, present, change over a specified period and whether this change was intentional)

• Skin, hair, and nails: rash or eruption, itching, pigmentation or texture change; excessive sweating, unusual nail or hair growth

• Head and neck: frequent or unusual headaches, their location, dizziness, syncope; brain injuries, concussions, loss of consciousness (momentary or prolonged)

• Eyes: visual acuity, blurring, double vision, light sensitivity, pain, change in appearance or vision; use of glasses/contacts, eye drops, other medication; history of trauma, glaucoma, familial eye disease

• Ears: hearing loss, pain, discharge, tinnitus, vertigo

• Nose: sense of smell, frequency of colds, obstruction, nosebleeds, postnasal discharge, sinus pain

• Throat and mouth: hoarseness or change in voice; frequent sore throats, bleeding or swelling of gums; recent tooth abscesses or extraction; soreness of tongue or buccal mucosa, ulcers; disturbance of taste

• Lymphatic: enlargement, tenderness, suppuration

• Chest and lungs: pain related to respiration, dyspnea, cyanosis, wheezing, cough, sputum (character and quantity), hemoptysis, night sweats, exposure to tuberculosis; last chest radiograph

• Breasts: development, pain, tenderness, discharge, lumps, galactorrhea, mammograms (screening or diagnostic), breast biopsies

• Heart and blood vessels: chest pain or distress, precipitating causes, timing and duration, relieving factors, palpitations, dyspnea, orthopnea (number of pillows), edema, hypertension, previous myocardial infarction, exercise tolerance (flights of steps, distance walking), past electrocardiogram and cardiac tests

• Peripheral vasculature: claudication (frequency, severity), tendency to bruise or bleed, thromboses, thrombophlebitis

• Hematologic: anemia, any known blood cell disorder

• Gastrointestinal: appetite, digestion, intolerance of any foods, dysphagia, heartburn, nausea, vomiting, hematemesis, bowel regularity, constipation, diarrhea, change in stool color or contents (clay, tarry, fresh blood, mucus, undigested food), flatulence, hemorrhoids, hepatitis, jaundice, dark urine; history of ulcer, gallstones, polyps, tumor; previous radiographic studies, sigmoidoscopy, colonoscopy (where, when, findings)

• Diet: appetite, likes and dislikes, restrictions (because of religion, allergy, or other disease), vitamins and other supplement, caffeine-containing beverages (coffee, tea, cola); food diary or daily listing of food and liquid intake as needed

• Endocrine: thyroid enlargement or tenderness, heat or cold intolerance, unexplained weight change, polydipsia, polyuria, changes in facial or body hair, increased hat and glove size, skin striae

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