OnExam

Collecting the following information is helpful both in framing the patient, their risk factors, and potential pathologies, but also in documenting the context of the interview.

  • Date and time of history
  • Full name
  • Date of birth/age
  • Gender
  • Marital status
  • Occupation
  • Source of history (e.g. patient, family members, friend, police officer)
    • Reliability should be documented if relevant

References

  1. Bickley LS, Szilagyi, PG. The Health History. In: Bates’ Guide to Physical Examination and History Taking. 9th ed. Philadelphia: Lippincott Williams & Wilkins; 2007: 6-7.