Al HaYaT MedicosA careful history leads to the diagnosis in most patients, and it is the core of every OSCE history station and clinical long case. This checklist gives you a reliable structure that you can use with any patient. Practise it until the order becomes automatic, then adapt it to the presenting complaint.
1. Introduction and consent
- Wash or sanitise your hands.
- Introduce yourself with your name and role.
- Confirm the patient's name, age and (if needed) date of birth.
- Explain what you would like to do and ask for consent.
- Make sure the patient is comfortable and that you have privacy.
2. Presenting complaint (PC)
Ask an open question such as "What brought you in today?" and let the patient speak without interrupting. Record the main complaint in the patient's own words, with its duration.
3. History of presenting complaint (HPC)
Explore the complaint in detail: when it started, whether it was sudden or gradual, how it has changed, what makes it better or worse, and any associated symptoms. For pain, the SOCRATES framework is easy to remember:
- Site — where exactly is the pain?
- Onset — when did it start, and was it sudden or gradual?
- Character — sharp, dull, burning, crushing, colicky?
- Radiation — does it spread anywhere?
- Associated symptoms — nausea, sweating, fever, breathlessness?
- Time course — constant or intermittent, and how has it changed?
- Exacerbating and relieving factors.
- Severity — for example on a scale of 0 to 10.
Also ask about relevant red-flag symptoms for the complaint, such as weight loss, night sweats or bleeding.
4. Past medical and surgical history (PMH)
Ask about long-term conditions (for example diabetes, hypertension, asthma, tuberculosis), previous hospital admissions, operations, and blood transfusions.
5. Drug history (DH) and allergies
- Current medicines, including dose and frequency.
- Over-the-counter, herbal and traditional remedies.
- Allergies — and what reaction occurred.
- Adherence: is the patient actually taking the medicines?
6. Family history (FH)
Ask about illnesses in parents, siblings and children, especially heart disease, diabetes, cancers and inherited conditions. Note consanguinity where relevant.
7. Social history (SH)
- Smoking (pack-years) and other tobacco use.
- Alcohol and recreational drug use, where relevant.
- Occupation and exposures.
- Home situation, support, and how the illness affects daily life.
- Recent travel.
8. Systems review
Briefly screen the other body systems — general, cardiovascular, respiratory, gastrointestinal, genitourinary, neurological, musculoskeletal and skin — to pick up anything the patient has not mentioned.
9. Ideas, concerns and expectations (ICE)
Ask what the patient thinks is causing the problem, what worries them most, and what they hope will happen. This builds trust and often reveals important information.
10. Summarise and close
Summarise the history back to the patient to check you have understood it correctly, ask if there is anything else they would like to add, and thank them. In an exam, finish by presenting a short summary and your most likely differential diagnoses.
Common mistakes to avoid
- Asking closed questions too early.
- Forgetting allergies.
- Missing red-flag symptoms.
- Not exploring the patient's concerns.
For a fuller guide with more examples, see our note History Taking Simplified.
Related notes
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Disclaimer
For education and exam preparation only. This is not medical advice and must not be used to diagnose or treat patients. Always follow current clinical guidelines and the advice of qualified senior colleagues. Spotted a mistake? Please tell us.