Personal Medical History

Constructing a Patient’s History

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

  • Approach patient
  • Chief complaint or concern (CC)
  • History of present illness (HPI)
  • Past history
  • Family history
  • Social history
  • 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.

Click on this link to download the free PDF: Medical History Cheat Sheet

Other free forms are available here: Free forms for Medical Students

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