History Taking Template Guide
The history-taking template is designed to be used on placement while you're talking to patients. Jot down some notes while talking to the patient in the first 5 boxes, noting significant parts of their history and symptoms. Once you've concluded the history you should examine the patient and write down any notable findings in the "O/E" box.
The final 3 boxes can be filled in after leaving the patient's bedside to allow you to reflect on the history properly and consolidate the patient's particular illness.
After having the whole page complete, you will be left with a complete history that you will be able to present to a doctor, nurse, consultant, anybody who you need to!
You can also use this notepad to help you revise common presenting complaints by writing down a patient's potential illness script. You can do this the following manner:
- Choose a diagnosis and write that in the diagnosis box.
- Go back and fill in the symptoms, medical history, family history, examination signs you would expect from a patient with that particular diagnosis.
- Then fill in how you would manage this patient.
Presenting Complaint (PC) = the answer the patient gives to the question "what brought you in?" What was the first concerning symptom in the patient's mind that led them to see a doctor. It is often the first thing a patient will tell you. This should be 1 short phrase e.g. stabbing chest pain; breathless when walking up the stairs, collapsed at work.
History of Presenting Complaint (HPC) = was this the first time the patient experienced this symptom? If not, how many times has it happened in the past? Have they had any other similar symptoms in the past? Did they have any other associated symptoms? Did the symptom come on gradually or suddenly? You can also use SOCRATES (site, consent, character, associated symptoms, timeline, exacerbating and relieving factors, severity) here.
Past Medical History (PMHx) = what other conditions does the patient have? Detail how long they've had the diagnoses and whether their conditions are well managed. You may even want to discuss how they accrued these diagnosis and symptoms that they tend to experience as a result. Are there any other significant illness or surgery the patient has had in the past which they have now recovered from?
Drug History (DHx) = what medications does the patient take? What dosage, how often and for which condition? Write down the patient's compliance with the regime and whether they experience any side effects.
Family History (FHx) - any significant illness in the immediate family (parents, siblings)? If so, note the age these conditions developed.
Social History (SHx) = Does the patient smoke, drink alcohol or use any recreational drugs? If they smoke, note the quantity and calculate their pack years - do the same for if they used to smoke in the past but have now stopped. Discuss details on the patient's drinking habits, including type of alcohol, volume and frequency to calculate their units per week. You can also discuss diet, exercise, lifestyle, living situation, social support system, pets, recent holidays etc.
On Examination = conduct an examination relevant to the patient's presenting complaint and note any findings. Make a note of the absence if significant symptoms which would help exclude pathology such as murmurs.
Differential diagnoses = list at least 3 potential conditions that the patient may have based on your history. Include at least 1 common condition and 1 serious condition it is important you rule out.
Diagnosis = 1 condition you think the patient is most likely to have.
Management = How would your diagnosed condition be managed?
Blue box denotes the part you should fill in after leaving the patient's bedside.