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Author: Wayne J. Altman, M.D.

Medical Interviewing and the Doctor-Patient Relationship
Fall 2011
W. Altman, MD
Tufts University School of Medicine

The Rest of the Story: Past Medical History, Social History, Family History

Past Medical History

  • Chronic Illnesses

  • Hospitalizations (dates, diagnosis, hospital)

  • Surgeries (may be on different list, depending on Electronic Medical Record)

  • Obstetrics History: GP: Gravida (# of pregnancies), Para (# of births)

  • Gynecology History: Period (LMP: first day of last menstrual period), Pap smears, Contraception

  • Health Maintenance: Colonoscopy, Mammogram, Immunization, etc.

Medications

  • Dose, Frequency

  • OTCs, Herbals, Vitamins, OCPs

  • Discrepancies frequent (between hospital discharge, office record, patient list, etc.)

Allergies to Medications

  • Document both the medication that the patient is allergic to and the reaction (document intolerances here also)

  • Document other allergies (i.e. food, seasonal, bee sting) in PMH

Social History

  • Rule of 3’s

    • General: Home, Work/School, Sex

    • Substances: Nicotine, Alcohol, Drugs

    • Safety: Seatbelts/Helmets, IPV, Guns

  • Nutrition/Exercise (if time allows): usually appears under SH

    • Nutrition: Servings of F/V per days, Servings of soda/juice per day, Servings of red meat per week

    • Exercise: Frequency, Duration, Intensity; additional activity

Family History

  • Start open-ended

  • Pertinent (-)’s: CAD, DM2, Colon/Prostrate CA, Mental illness, Substance abuse

  • Less important: family member with "cancer," or HTN, or high cholesterol