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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.