Dermatology history taking

INTRODUCTION

1 Introduces themselves

2 Confirms patient details

3 Establishes presenting complaint using open questioning

HISTORY OF PRESENTING COMPLAINT

4 Onset / duration

5 Course

6 Location / distribution of skin problem

7 Exacerbating / relieving factors

8 Associated symptoms

9 Previous episodes

10 Previous or current treatment for skin problem

11 Contact history / sun exposure

12 Ideas / Concerns / Expectations

KEY SYMPTOMS

13 Pain

14 Itch

15 Bleeding / discharge

16 Blistering

17 Associated systemic symptoms - fever / malaise / weight loss / arthralgia

PAST MEDICAL HISTORY

18 Skin cancer / other dermatological conditions

19 Atopy - eczema / hay fever / asthma

20 Medical conditions

DRUG HISTORY

21 Skin treatments - creams / ointments / UV therapy / biologics

22 Prescribed medications / antibiotics

23 Over the counter medication / herbal remedies

24 ALLERGIES

FAMILY HISTORY

25 Skin conditions / skin cancer / atopy

SOCIAL HISTORY

26 Smoking history / Alcohol intake / Recreational drug use

27 Home situation / Level of functional independence

28 Occupation (including relation of dermatological symptoms to work)

TRAVEL HISTORY

29 Where? / How long? / Exposure to disease? / Sun exposure?

SYSTEMIC ENQUIRY

30 Screens for symptoms in other body systems

CLOSING THE CONSULTATION

31 Thanks patient

32 Summarises salient points of the history

KEY COMMUNICATION SKILLS

33 Active listening

34 Summarising

35 Signposting

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