Patient’s Personal and Family Medical History Form (Questionnaire)

What Is Medical History?

A medical history or anamnesis (Greek anamnesis = recalling) is a summary of your symptoms, past diseases, therapies, medical investigations and diagnoses (personal medical history), and chronic diseases running in your family (family medical history), as you reveal them to your doctor (Picture 1).

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Picture 1. Collect all important details about your health problem
and reveal them to your doctor

Below questionnaire may help you to recall all details, which may help your doctor to give you a correct diagnosis and treatment.

Medical History Questionnaire

1. Basic Data

Sex, age, height, weight, occupation, marital status.

2. Current Symptoms

a) Your main current symptom (the one you have right now) with exact description:

  • What exactly is your main symptom and how severe it is: does it prevent you to eat, sleep, walk, etc.?
  • Where exactly does the symptom appear, and, if pain, does it radiate to other parts of the body?
  • When did the symptom appear the first time, did it appear slowly or suddenly, is it present all the time, how long does it it last after it appears?
  • What triggers the symptom (food, exercise, body position, environmental temperature, etc.) and what relieves it (rest, medication, etc.)?
  • If it is an injury – what happened?

patient and doctor

b) Your other current symptoms (write details of each symptom with the help of “what”, “where” questions as showed above):

c) Time course of your current disease, eventual tests with results and diagnoses given by other doctors, therapies you have tried and their effect.

d) Have you traveled out of your country in last 6 months?

3. Complete Personal Medical History

Childhood and other diseases, injuries, allergies, symptoms, investigations (with results), diagnoses, vaccinations and therapies (and their effect) from birth to present.

4. Current Medications

Current prescribed and over the counter medicines, supplements, physical or other therapy.

5. Life Style

Physical activity, diet, stress, living conditions, smoking, alcohol, street drugs.

6. Family History

1. Does anyone of your close relatives (sisters, brothers, parents, grandparents, children, uncles, aunts) has/had any of the following diseases:

  • Allergies
  • Cancer
  • Diabetes
  • Venous thrombosis or atherosclerosis
  • Angina pectoris (heart related chest pain) or heart attack
  • Stroke
  • Psychiatric disease
  • Other chronic diseases

2. If any of your close relatives has died, at which age and from what cause has he or she died?

Medical History of a Small Child

Children under 5 years of age often can not describe their symptoms clearly, so their parents should speak for them and provide the following information:

NOTE: No official medical history form exists, so your doctor might skip something what you think it is important; in this case just mention all health-related details that left on your mind to your doctor; avoid long stories, though.

After taking your medical history, doctor will likely want to perform a physical examination and sometimes will need to order certain medical investigations before giving you a diagnosis.

Related Articles:

References:

  1. Medical history – a guide for physicians (thelancetstudent.com)

 

About Jan Modric (249 Articles)
Health writer

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  • sonson

    takes the mystery out of doctor visits, thanks for this form

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  • carmel smith

    tingling in legs what does this mean

    carmel smith

  • Jan Modric

    carmel smith,

    tingling is a sensation like “ants crawling” or “prickling”. It occurs when your leg awakens after being fallen asleep (when you are sitting and you cross your legs, or during certain sleep positions). When it occurs in legs, it is often a symptom of a nerve disorder (like a pinched nerve in the lumbar spine), but it can be also a symptom of conditions resulting in low blood perfusion (thrombosis, low blood pressure, hypoglycemia). Tingling by itself is not dangerous, but (if persistent) can reflect a serious neurological disorder.

  • pals

    Fist notices after exercise at gym, both knees & legs both feel heavy and dull ach, standing & sitting. Very uncomfortable to walk. Looks like im walking in discomfort and looks like ive had a drink too many. Having to hold rail up & down stairs. Cant run up/down stairs. Dull heavy ach whilst sitting. After resting after night time sleep, the dull ach pain immediately returns. Lower dull back ach.
    Any ideas what this might be?

  • Jan Modric

    pals,

    pains in the legs accompanied with lower back pain and changing with body position are probably due to a disorder in the lower back, like a bulging disc or arthritis resulting in a pinched sciatic nerves that innervate the legs. An orthopedist or neurologist can say more.

  • urcrazee2004

    had a microdiscectomy and a hemilaminectomy about 5 months ago on my L4 L5 disc. I also had a herniation on my L5 S1 that was not operated on. Right after surgery my Dr told me that I would reherniate my disc within a week to a year and that I would have to have a fusion. I went and did my 16 sessions of PT and during so I notices numbness in my feet going from my akeles tendon along the outside of my foot to the toes and pad. I also was experiencing bone on bone clicking at the site that was operated on which cause pain. I informed my dr of this and he stated that until my leg went completely numb I don’t have to see him again. A month and a half later I am still experiencing back pain daily (not debilitating) and numbness in calves and feet on both legs more intense or left side and a little pain on back of left leg under buttock. I am meeting with my dr in 2 weeks and I want to be clear that I am concerned about this. What are some options on what it may be? I don’t know if I reherniated L4-5 or if the herniation on L5-S1 became worse, or I read about FBSS or possible permanent nerve damage. I just don’t want to be rushed out of the office again after 5 mins. I want to be able to ask question and find a solution. I drive to long of a way to see him and wait even longer to get an apt to be rushed out with no solution other than time will heal it, it’s been 5 months. Please help with any information possible or questions I could ask. I know I should not be intimidated by my neurologist but he makes me feel so dumb when I ask questions, and his only response seems to be “give it time and you’ll be fine.”

  • Jan Modric

    urcrazee2004,

    the nerve fibers arising from L5/S1 spinal root innervate a certain area on buttocks, on the back part of the legs, and lateral part of feet. So, if these areas are affected, a bulging/herniated disc at L5/S1 is possible. This can be confirmed by a CT or MRI. The extent of disc bulging does not necessary correlate with severity of symptoms. Anyway, they are your symptoms from which it should be decided, do you need another operation or not. Waiting that your legs will go completely numb does not seem appropriate to me. It is one nerve that innervates one part of leg, so for complete leg numbness, several nerves would needed to be pinched. A part of the skin innerrvated by one spinal root is called dermatome. Here is one picture of body dermatomes. Please, be aware that these dermatomes may overlap considerably, and they differ from person to person a bit, so it is not a good idea to have some hard fights with surgeons, when it comes to a question of centimeters. Still, roughly, distribution of symptoms among dermatomes can show which spinal root is affected. L4/L5 reherniation would cause symptoms on the front side of the leg(s) and on the inner (medial) side of the foot (feet). Like said, L4/L5 and L5/S1 dermatomes may overlap a bit, so I cannot judge from here which disc was herniated, if any, but a CT or MRI can show this.

    Theoretically a permanent nerve damage after prolonged pressure on it is possible, but I believe this has not yet occured in your case. Failed Back Surgery Syndrome (FBSS) would mean either an operation was not successful (complete), or some scar tissue has developed later around the operating site and is interfering with nerves. Not all detailes of eventual FBSS may be seen on the MRI, but often only during an operation. I can’t say what clicking bones mean in your case and I don’t want to guess, but a surgeon should have some idea.

    So, it is possible your L5/S1 nerve root is affected by a herniated disc, so you can ask the doctor about MRI. The same MRI could show eventual disorder at L4/L5 level, but not necessary in details. It sounds like a good idea to reserve some time in advance to discuss the situation with the surgeon who has operated you, and then, after eventual MRI, to discuss options again. My personal opinion is that if you have symptoms that affect your life, there is no reason to wait further to have more symptoms. You said you have a herniated disc at L5/S1 and this will not likely just heal. It can pretty much only become worse and would likely need an operation sooner or later. If symptoms don’t seem to improve at least slowly and even not after physiotherapy, the “time” itself won’t likely help.

    Your symptoms may be called “sciatica”. It would be hard for you to collect information to the extent to be able to talk with surgeons on professional level, so for you, it is important to feel – do you trust a surgeon or not. If not, find another experienced and reliable one.

    So, questions for the doctor could be:
    1. Do your symptoms (describe him exact areas involved) reflect a disorder at L5/S1. Would MRI be needed?
    2. What can clicking bones mean?
    3. If you have an operation at L5/S1 level, would a recheck of the L4/L5 during the same operation would be needed.
    Be aware that doctor might not be able to answer all questions without a new MRI.

  • jodie097

    jan modric,
    you told me to have a look at this form thing and i don’t really understand what i have to do with it. i have quite a lot of the things on the list, (loads of my joints click, all my fingers click when i bend them, my jaw clicks whenever i move it forward; my eyes sometimes sort of go really blurry or suddenly navigate away from my focus[i went to the optitions and they said it was just minor muscle spazams so thats okay], i get palpitations, i suffer from insomnia where i cant get to sleep at night, and i just generally have a few things on the list) sorry to go on, but i dont know what they mean? thanks, Jodie

  • Jan Modric

    jodie097,

    the point of the questionnaire is to read it through to help you recall all symptoms you have now or you had in the past and put them in a time line, so a doctor, when you tell him/her all your problems can think if the symptoms speak for any particular disease. If you don’t understand certain terms, just skip them. You don’t need to mention things that do not cause any pain or problems, like klicking fingers, but it is important to mention difficulty breathing at night, mucus in the throat and such.

  • deetee857

    Jan, Thank you for your past help with my chronic back and leg symptoms. My question today is what type of doctor should I see next. Without a diagnosis, I find it hard to tame my anxiety. I have seen 2 neurologists, an orthopedist, a DO, and a chiropractor. My DO wants me to take neurontin for pain. I feel like it is putting a bandaid on this until someone says what it really is. I have been told that it is not MS, and no bulging discs only DDD. I have chronic back ache and my legs ache every day. It doesnt keep me from sleep or doing anything else but I cant stop thinking about it because it is always there. IT is despressing! Please give me a suggestion. Thanks.Dee

  • Jan Modric

    deetee857,

    I encourage you to write down your symptoms on the paper in this manner:

    Pain: where exactly, when, triggers, relievers.
    Other symptoms: what, where, when, triggers, relievers.

    For example: pain in both calves, all the time (?), worse at night, relieved by walking (?).

    Describe your back, hip and calves pain separately with answers to all above questions. Also eventual other symptoms. The combination of symptoms may remind a doctor to a certain typical disorder, for example:
    – sciatica, caused by DDD. Please note that DDD can be enough to cause pains in the leg, without any bulging disc been identified.
    – psoas muscle syndrome
    – piriformis muscle syndrome
    – fibromyalgia

    I believe an orthopedist should be able to give you a diagnosis. Try to tell your symptoms in a short, factual way, so the doctor won’t get an impression you are complaining about “everything”.