1.6 Basic Components of Medical History Gathering

Basic Components of Medical History Gathering

  • Demographic information.
    • Age, gender, who the patient resides with, address, phone.
  • Presenting Complaint.
    • Detailed description of why they are being seen.
  • Medical history.
    • Patient illness, injury, or hospitalization; medications, history of previous abuse or assault.
  • Social history.
    • Alcohol consumption, smoking, family relationships and social support.
  • Family history.
    • This may not be relevant for the reason why the patient has presented for an examination.
  • Head to toe review of each system.
Peart, P. (2022)