History Taking and Interview Techniques

Comprehensive Adult Health History

Source of the history or referral

Can be the patient, a family member, a friend,

an officer, a consultant or a medical record

Comprehensive Adult Health History

Chief complaint(s)

• Use the patient’s own words
• If no overt complaints report the goal (for example ‘admitted for a regular checkup’)

Comprehensive Adult Health History

History of present illness

• The onset of the problem
• The description of the problem
• Intensity
• The setting in which it has developed
• Exacerbating, remitting factors
• Its manifestations
• Any treatments

Comprehensive Adult Health History

Always listen to the patient, they might be

telling you the diagnosis

William Osler

Comprehensive Adult Health History

The data flow spontaneously from the patient,