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History taking
INTRODUCTION
TO MEDICINE
HISTORY TAKING

Dr. Wasim Uddin
Consultant Physician
POF Hospital Wah Cantt
What is History?
• Getting to know the patient.
• Why has he come to
doctor/hospital?
• Getting as much detail about his
complaints as possible.
How to Start?
• Introduce yourself.
• Take patients permission.
• Stand on Patient’s Rt. Side of
bed.
• Listen carefully.
Patient’s Details
• Name
• Age
• Sex
• Address
• Occupation
• Date of Admission
Presenting Complaints
• Complaints which has brought
the patient to the doctor.
• Enumerate them in a
chronological order.
• Mention time.
• Use simple descriptive terms.
Example
•
•
•
•

Name
Age
Sex
Address

:
:
:
:

ABC
60 years
Male
WMC

• Occupation

:

Driver

• Presenting Complaints:
– Fever
:
– Cough
:
– Blood in sputum :

3 Months
6 wks.
3 days
History of Present
Illness
• Detail about each of the
presenting complaints.
• Use simple language.
• Avoid using diagnosis.
• Do not ask leading questions.
History of Present
Illness
• Onset of each complaint.
• Progress and course of
complaint.
• Aggravating or relieving factor.
• Associated symptoms.
History of Present
Illness - Example
• Pain
– Onset
– Site
– Character
– Radiation
– Course
– Aggravating/relieving factors
– Associated symptoms
History of Present
Illness
• Facilitate patients by simple
questions.
• Try to stop unnecessary
details.
• Be ready for any emotional
outburst.
• Never argue – postpone
interview if needed.
Past History
• Ask about significant
relevant past medical
history.
• Cut out on unnecessary
detail.
Treatment History
• Prescription drugs.
• Other medicines.
• Ask for any drug allergies.
• Treatment compliance.
Family History
• Relevant family history.
• Open ended questions.
• Know about genetics.
• Ask about other household
members.
Social History
• Occupation.
• Income – Other family
support.
• Type of house.
• Personal habits – Smoking,
drugs.
• Travel History.

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History taking