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).
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?
b) Your other current symptoms (write details of each symptom with the help of “what”, “where” questions as showed above):
- GENERAL: fever (in F° or C°), feeling cold, pain, tenderness, lightheadedness, dizziness, nausea, weakness, tiredness, unexpected weight gain/loss, swoolen lymph nodes, sleeplessness, mood change (depression, anxiety, irritability, panic attacks, etc.)
- SKIN: dry skin, sunburn, excessive sweating, hot flashes, body odor, itch, paleness, skin discoloration (blue, red, yellow – jaundice), rash (itchy rash, non-itchy rash, newly appearing nevus, blister, hives, scaling, crust), skin peeling, non-healing wounds, bleeding, facial hair in women
- HEAD: headache, facial pain, itchy face, itchy scalp, clicking jaw, hair loss
- NEUROLOGICAL: seizures, unconsciousness, unusual sensations, tingling or numbness, impaired balance
- EYE: blurred vision, itchy eyes, dry, wet or red eyes, swollen eyes, eye pain, itchy eyelid(s), dropped eyelid
- NOSE: nasal congestion (stuffy nose), nasal discharge, sneezing, nosebleed, changed sense of smell
- EAR: ringing in the ears, ear discharge, pressure in the ear, impaired hearing
- MOUTH: bad breath, caries, mouth ulcers, drooling, tingling lips
- THROAT: itchy throat
- BREAST: breast pain, breast swelling, nipple discharge
- MUSCLE: muscle cramps, tremor
- RESPIRATORY: difficulty breathing (after exercise, in rest?), wheezing, cough (dry, mucus – what color, coughing up blood?)
- HEART: rapid, slow or irregular heart rhythm, palpitations, chest pain (radiating to the left arm?)
- GASTROINTESTINAL: poor appetite, excessive hunger, craving for certain food, nausea, heartburn, vomiting (blood?), hard or painful swallowing, excessive burping, sulphur burps, abdominal pain or cramps, bloating and flatulence, foul smelling gas, changed stool color, lose stools (sudden or chronic diarrhea), mucus or blood in the stool, urgency, incontinence, constipation, anal itch
- URINARY: changed amount, color or smell of the urine, bloody urine
- GENITAL: penile or vaginal discharge, vaginal pain, itch or odor, poor sex drive
- LIMBS: itchy legs, pain, weakness, cramps, swelling, swollen legs or feet, swollen arms or hands, swollen or painful joints, reduced mobility, cracked heels, cracked nails
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:
- Venous thrombosis or atherosclerosis
- Angina pectoris (heart related chest pain) or heart attack
- 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:
- Weight at birth, when did the child start to walk and speak
- Diet: time of weaning, formula used
- COMMON ISSUES: sleeplessness (insomnia) , night terrors, toddler’s diarrhea, stomach flu
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.
- Medical history – a guide for physicians (thelancetstudent.com)