Professional Documents
Culture Documents
Past Medical History: Have you ever had any previous medical problems?
Drug history
Are you on any current medications? [prescribed (by who), over the counter, herbal]
Are you on any recreational/illicit drugs?
Have you recently started or stopped any medications? Since when and why?
Allergies: are you allergic to anything?
Family history
Do any of your family members suffer / suffered from any medical conditions?
Are both of your parents alive and well? And if someone died, did they die from any
medical conditions? ( make it appropriate to patient )/
Social history:
Alcohol (if yes how much and how long?), smoking (if yes how much and how long?),
occupation, stress (do you consider your occupation to be stressful?), exercise, housing,
hobbies, travel (have you recently travelled somewhere?)
System enquiry:
Current prescribed medication: name of the drug, strength, dose/frequency, route, duration of
therapy (how long have you been taking it). Are you taking the medication as prescribed?
Past medications taken in the past: have you recently taken or previously stopped any
medication? And why?
Hypersensitivity: Allergies?
Concordance with therapy: do you adhere to the treatment? Are you taking the medications as
prescribed? Do you remember to take your medication regularly? Dose wise and frequency wise
Age / appearance
Extra medicines: have they taken anything already to treat the symptoms they are suffering from.
History
Other symptoms: are you experiencing any other symptoms than the ones you came today for?
Diarrhoea