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Patient Interview Guide: Essential Questions for Medical History Taking, Study notes of History

Hasselt UniversityHistory

A comprehensive patient interview guide for healthcare professionals. It covers various topics including demographic information, chief complaint, history of present illness, past medical history, allergies, current medications, immunization status, family history, social history, and review of systems. The guide offers questions to ask for each topic and emphasizes the importance of obtaining accurate and detailed information.

Typology: Study notes

2021/2022

Uploaded on 08/05/2022

jacqueline_nel
jacqueline_nel 🇧🇪

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PATIENTINTERVIEWGUIDE
Obtainpertinentdemographicinformation(sometimesyoualreadyhavethisinformationfromthechart)
Maynotneedtoaskalloftheinformationlisted,especiallyifitisaquickinterview
ChiefComplaint
“Whatbringsyouheretoday?”
HistoryofPresentIllness
Maynotallbenecessary,dependingonthechiefcomplaint;usejudgment–mayalsoneedtoelaboratebeyondthese
questions
Whereitislocatedonthebody(suchaspain)
o Doesitradiate
Timing
o Whendiditstart/howlonghasitbeengoingon?
o Isthisanewproblem/firsttimehavingthisproblem?
o Intermittentorconstant?
o Ifintermittent,howlongdoesitlast,andhowoftendoesitoccur?
Quality(particularlyimportantifpain)
o Dull,sharp/knife‐like,achy,pressure,tightness,tingling,etc
Severityorintensity
Whattriggersthesymptom
o Whatwereyoudoingwhenitstarted
o Whatcausesittooccur
Alleviating/aggravatingfactors
o Whathelpsit
o Whatmakesitworse
Anyothersymptomsthatyouhave?
PastMedicalHistory
Ifpossiblefindouthowlongcurrentillnesseshavebeengoingon,andobtaindatesforanyevents
Itmaynotbenecessarytoaskeveryquestion,ifnotpertinent
Childhoodillnesses
Adultillnesses
o Includeanyrecentillnesses(i.e.infection)
Surgeries
Hospitalizations
Injuries
Trauma
Screeningtestsorexams
Allergies
Promptwithcommonallergies,ifneeded(aspirin,sulfa,penicillin)
Makesureyouincludethereaction
Alsoaskaboutseasonal,environmental,contactandfoodallergies
pf3

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PATIENT INTERVIEW GUIDE

Obtain pertinent demographic information (sometimes you already have this information from the chart) May not need to ask all of the information listed, especially if it is a quick interview Chief Complaint “What brings you here today?” History of Present Illness May not all be necessary, depending on the chief complaint; use judgment – may also need to elaborate beyond these questions  Where it is located on the body (such as pain) o Does it radiate  Timing o When did it start / how long has it been going on? o Is this a new problem / first time having this problem? o Intermittent or constant? o If intermittent, how long does it last, and how often does it occur?  Quality (particularly important if pain) o Dull, sharp/knife‐like, achy, pressure, tightness, tingling, etc  Severity or intensity  What triggers the symptom o What were you doing when it started o What causes it to occur  Alleviating / aggravating factors o What helps it o What makes it worse  Any other symptoms that you have? Past Medical History If possible find out how long current illnesses have been going on, and obtain dates for any events It may not be necessary to ask every question, if not pertinent  Childhood illnesses  Adult illnesses o Include any recent illnesses (i.e. infection)  Surgeries  Hospitalizations  Injuries  Trauma  Screening tests or exams Allergies  Prompt with common allergies, if needed (aspirin, sulfa, penicillin)  Make sure you include the reaction  Also ask about seasonal, environmental, contact and food allergies

Current Medications  Prescribed medications (also determine when started and if any doses have been changed recently) o Questions to ask about medications  Name of medication  Dosage and frequency / change in dosage (make sure you have correct units)  The way the patient is actually taking it (don’t assume it’s the same as written)  The reason the patient is taking the drug  How long taking it  Does the patient feel it is working  Has the patient had any issues or side effects from it  Compliance / remember or able to take it (can ask how the patient remembers to take it) o Remind of typically “forgotten” medications:  Samples  Birth control pills  Creams/ointments  Eye/ear medications  Inhalers  Recent / current antibiotics  Clarify any PRN medications for frequency of use  Over‐the‐counter medications o Herbal / natural products (including household remedies) o Vitamins  Immunization status Family History May not always be important to ask this information (use judgment)  Age/current health status of parents, siblings and grandparents (if applicable)  Based on judgment could ask about similar symptoms or conditions in family Social History May not need to ask all of these (use judgment)  Occupation  Tobacco/Alcohol  Illicit drugs  Caffeine use (if applicable)  Diet (especially if on a special diet; or should be on one but is not)  Exposure (if applicable, such as with infections)  Sexual partners (if applicable)  Living situation  Ability to perform activities of daily living (if applicable)  Recreation  Safety situations (i.e. abuse; if applicable) Review of SystemsTypically asked as closed‐ended questions (yes/no); often will be filled out ahead of the visitMay not need to ask all of these questions, especially if focused interview/examination‐ use your professional judgment