Collecting a medical history is the first step in the physician's process of diagnosing and treating a patient. It also serves as an important moment for effective doctor-patient communication and for establishing a good rapport. Emphasis is placed on the development of communication skills.
Methods of Collecting Medical History
In order to assess the medical condition accurately, it is necessary to inquire about the health status thoroughly and listen to the patient's statements attentively. Adequate doctor-patient communication serves as the foundation for properly evaluating and managing a patient's condition. Effective communication not only ensures that the collected medical history is comprehensive and accurate but also increases the patient's sense of security, improves the treatment experience, enhances compliance, and leads to better therapeutic outcomes, while reducing disputes. A polite attitude and considerate language should be maintained during the conversation. Questions about medical history should have a clear purpose, and key information must not be overlooked to avoid misdiagnosis or missed diagnoses. Open-ended and exploratory questioning techniques are recommended, while suggestive or subjective assumptions should be avoided. For critically ill patients, initial comprehension of the condition should take precedence over comprehensive questioning, allowing for immediate intervention and treatment. For referrals from other institutions, medical documentation from the previous facility should be retrieved as essential reference material. In situations where patients are unable to speak for themselves, family members or close acquaintances thoroughly familiar with the patient’s condition can provide information. Efforts should also account for the patient’s privacy, particularly in cases where they are unwilling to disclose certain details (e.g., sexual history). In such instances, supplementary information may be gathered after conducting a physical examination or ancillary investigations when the condition has been better understood.
Components of Medical History
General Information
This includes the patient’s name, gender, age, place of origin, occupation, ethnicity, marital status, address, date of admission, date of history-taking, the person providing the history, and the reliability of the data. If individuals other than the patient are providing the information, their relationship to the patient should be specified.
Chief Complaint
This refers to the primary symptoms (or signs) prompting the patient to seek medical attention, along with their duration. The objective is to provide a preliminary estimation of the potential scope of the disease. The chief complaint should be concise and typically not exceed 20 words. Symptoms rather than disease names are used. Common gynecological symptoms include vulvar pruritus, vaginal bleeding, increased vaginal discharge, amenorrhea, infertility, lower abdominal pain, and pelvic lumps. If multiple symptoms are present, such as amenorrhea, vaginal bleeding, and abdominal pain, they should be documented in chronological order, e.g., "Amenorrhea for × days, vaginal bleeding for × days, and abdominal pain for × hours." If asymptomatic conditions like uterine fibroids are detected during an examination, the chief complaint is documented as "Uterine fibroids detected during examination for × days."
Present Illness
Refers to the onset, progression, and management of the current condition, serving as the core part of the medical history. It is recorded chronologically and should start with the primary symptoms described in the chief complaint. Areas of focus include the time of onset, primary symptoms, location, characteristics, possible triggers, factors that alleviated or exacerbated symptoms, associated symptoms, negative symptoms of diagnostic value, diagnostic and therapeutic measures undertaken, and their outcomes. General conditions such as changes in sleep, appetite, weight, and bowel and urinary habits should also be noted. Positive or negative findings relevant to differential diagnosis should also be included. Other illnesses or conditions requiring treatment that are unrelated to the current condition and any medications used should be recorded in a separate section following the main account of the present illness.
Menstrual History
Includes the age at menarche, menstrual cycle and duration, volume of menstrual flow, and symptoms during menstruation. For instance, menarche at 11 years of age, a cycle of 28–30 days, and duration of 4 days would be documented as "11 × 4/(28–30)." The volume of menstrual flow can be assessed based on the frequency of sanitary pad changes, clotting, and blood color. Symptoms include any discomfort, dysmenorrhea, pain location, nature and severity of the pain, and when the pain started or resolved. The date of the last menstrual period (LMP), its duration, and flow should be routinely noted. If bleeding differs from normal menstruation, the start date of the previous menstrual period (PMP) should also be documented. For postmenopausal patients, the age of menopause and any symptoms such as vaginal bleeding or increased vaginal discharge should be noted.
Marital and Reproductive History
Includes the number of marriages and age at each marriage, whether consanguineous marriages occurred, the health of the male partner, the presence of sexually transmitted infections, and the sexual history of both partners. Multiple sexual partners increase the risk of sexually transmitted infections (STIs) and cervical cancer, and details regarding sexual partners should be clarified. Reproductive history includes the number of full-term deliveries, preterm deliveries, and abortions, followed by the number of surviving children, recorded using four Arabic numerals. For instance, one full-term delivery, no preterm deliveries, one abortion, and one living child would be documented as "1-0-1-1" or "G2P1" (pregnancy 2, parity 1). Details about the mode of delivery, complications such as difficult labor, neonatal outcomes, and postnatal issues such as hemorrhage or puerperal infections are noted. Information on induced or spontaneous abortions, ectopic pregnancies, or molar pregnancies, as well as measures for treatment and the date of the last delivery or abortion, are included. Methods of contraception, their effectiveness, and any history of infections like vaginitis or pelvic inflammatory disease (including the type and treatment) are documented.
Past History
This refers to the patient’s prior health status and medical conditions. Topics include overall health, diseases (e.g., chronic illnesses), infectious diseases, vaccination history (including HPV vaccines), history of surgeries or injuries, history of blood transfusions, and any drug allergies. Systematic questioning about various bodily systems is advised to ensure thoroughness. If specific conditions were previously diagnosed, the disease name, onset time, and outcome of treatment should be detailed.
Personal History
This includes lifestyle and living conditions, place of birth, past residences, and habits such as smoking, alcohol consumption, or substance use.
Family History
This involves the health status of parents, siblings, and offspring. The presence of hereditary conditions (e.g., hemophilia, albinism) or diseases with potential genetic links (e.g., diabetes, hypertension, breast cancer, or ovarian cancer) should be noted, along with infectious diseases such as tuberculosis among family members.