1.7 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.
    • Members of the household, school and grades, who cares for the child if not school age, do the parents work outside the home.
  • Family history.
    • Parent/caretaker illness or injury; parent/caretaker previous abuse or assault.
    • It’s important to ask the parent/caregiver about prior abuse/assault to help determine if additional therapy or intervention for the caregiver needs to be considered.
  • Systems Review.
    • Head to toe review of each system.
  • Caregiver Interviews.
    • Include notes, including quotes, by parents and caregivers.
Peart, P. (2022)