A competent, well-trained physician must be able to construct a complete personal medical history in a clear and concise manner and perform a thorough physical examination so that a specific diagnosis can be made or an avenue of approach to the patient’s specific problems can be entered. When a physician has attained this end, he or she has completed one of the most fundamental tasks required in building a solid foundation upon which correct diagnosis and management rest. When this ability is further perfected and combined with integrity, respect, compassion, empathy for the patient, trust, and commitment portrayed in a professional manner, the young physician will be not only a credit to medicine, but will be a true physician.
7 Steps to Taking a History
Chief complaint or concern (CC)
History of present illness (HPI)
Review of systems
Download the free Medical History Sheet
I’ve compiled a “cheat sheet” of the basics for taking a medical history. For any medical students studying physical diagnosis, this list of prompts and questions will be an invaluable resource.