How to Take a Medical History
by Allen B. Ury
As a medical assistant, you will likely be asked to take medical histories. A medical history is a record of a patient’s condition, past and present. It documents:
- Physical or mental conditions of which the patient is aware.
- Major illnesses the patient may have suffered.
- Surgeries the patient may have undergone.
A medical history also contains as much information as you can get about any pain, discomfort or other medical issues the patient may be experiencing.
Getting accurate medical histories is vitally important to a doctor’s ability to deliver proper care. A good history can help speed the diagnosis of a current complaint. It can point the way to proper treatment. And it can alert a doctor to avoid medications that may cause more harm than good (such as when a patient is allergic to a family of drugs).
So how do you take a medical history? It is usually through a one-on-one private interview with the patient. Here are the basic steps:
1. Introduction. Begin by introducing yourself and explaining you are helping the doctor by taking a medical history. Be as friendly and open with the patient as you can to establish rapport and build trust. It is important the patient feels comfortable with you because you need to get full, honest answers.
2. Basic Personal Information. Confirm the patient’s name, address, phone number and emergency contact.
3. Current Complaint. Is the patient here today to address a specific complaint or just to get a periodic physical examination? If the patient has a current complaint, you need to get a full description of the issue. Questions to ask include:
- Where is the problem located?
- What are the general symptoms?
- When did this problem begin?
- Has it changed over time?
- Does it affect any other areas of the body?
- Does it vary depending on time of day?
- Does anything make the symptoms better or worse?
- Does the problem interfere with daily activities or sleep?
4. Current/Past Illnesses and Conditions. Part of any medical history is a record of any major illnesses or conditions from which the patient currently suffers, or which the patient has had previously. Ask about any current conditions that have been diagnosed, including:
- Hypertension (high blood pressure)
If the patient is female, is she pregnant?
Ask about childhood illnesses, including:
- Chicken pox
- Rubella (German measles)
Also confirm all immunizations the patient has had, including vaccines for polio, tuberculosis and DTP (diphtheria, tetanus and pertussis), as well as the childhood diseases listed above.
5. Surgeries and Procedures. Get the when’s and why’s about any past surgeries or other major medical procedures. Were they successful? Were there any complications? If the patient is over 50, did he/she ever have a colonoscopy?
6. Obstetrics. If your patient is female, you need to ask:
- Has she had any past pregnancies? If so, how many?
- Has she ever suffered any miscarriages?
- Were there any complications during pregnancy, such as hypertension, toxanemia (pre-eclampsia) or diabetes?
- Were the deliveries normal, or were C-sections required? If so, why?
- Has the patient ever had an abortion? If so, was it elective or for medical reasons?
7. Current Symptoms. Although the patient may have a specific complaint -- or no complaint at all -- you still want to look for signs of other conditions that may be contributing to the problem. Ask the patient if he/she is experiencing:
- Shortness of breath
- Chest pains
- Loss of appetite
- Swollen ankles
- Recent changes in bowel habits
- Blood in the stool
- Pain or burning while passing urine
- Back pain
- Joint pain
For men, you should ask about the presence of any penile discharge or problems with sexual functions.
For women, ask about the presence of any vaginal discharges and frequency of menstrual cycles. If the patient is currently going through menopause, when did she experience her last period?
8. Prescription Medications. Ask the patient to list all prescription medications he/she is currently taking.
9. Lifestyle. Many of our lifestyle choices directly -- or indirectly -- contribute to our health. You therefore want to ask your patient about:
- Marital status
- Average hours of sleep daily
- Tobacco use (now or in the past)
- Alcohol use (what and how often)
- Regular exercise (what and how often)
- Travels abroad (where and when)
- Fried food
- Spicy food
- Red meat
- Dietary supplements
- Recreational drug use (what and how often)
10. Family History. Since many diseases and conditions run in families, ask the patient about:
- Parents -- alive or dead? If dead, how?
- Siblings -- alive or dead? If dead, how?
- Any genetic diseases known to be present in the family line.
Conclude by asking the patient if there are any other issues or concerns that you should note.
The order in which you ask these questions will likely be determined by the doctor for whom you work. You will probably be given a form with these -- or similar -- questions in their preferred order.
Medical Assistant Career Training Available at Everest
Learning to take medical histories is just one of the areas you can study in the Medical Assistant career training program offered at Everest. At Everest, you can get the knowledge, training and experience you need to qualify for entry-level medical assistant positions in physicians’ offices and clinics throughout the United States.
For more information on the Medical Assistant career training program, just fill out and submit the Request More Information form on this page. A friendly Everest representative will get back to you immediately to answer all your questions.
Financial aid is available for those who qualify.
Programs and schedules vary by campus.