CHECKLIST FOR HISTORY TAKING (ENG 235)

YOU ARE THE DOCTOR TALKING TO THE PATIENT

No. STEPS & CRITERIA DONE NOTE
1 Say hello 
Introduce yourself - name & role
My name is ... and I will be your doctor today/I am in charge of the 
2
clinic today. 
(+) Hand sanitizer
3 Confirm patient details - name & DoB 
Explain the need to take history (as a doctor)
4 I need to ask you some questions before examining you. This will 
give me more information so that I can make a correct diagnosis.
5 Gain consent 
6 Ask about chief complaint (CC) 
Ask for details of CC:
. duration 
. location 
7
. severity 
. relieving or aggravating factors 
. medication 
8 Ask about other symptoms 
Ask about previous health:
9 . past medical history 
. family history 
10 Talk to the patient about next step 
Summarize the case 
A ... year-old male/female patient complaint of .... (details of CC).
11 (Other symptoms & previous health). In conclusion, I think the
patient is having an issue with his/her ... system.
(+) Make a possible diagnosis 
Communication skills (on a scale from 1-5; the higher, the better)
* Pronunciation ___
12 * Fluency ___
* Active listening to the patient ___
* Terminology in summary ___
COMMENT: TOTAL: