Name, gender, age, place of origin, place of birth, nationality, marriage, mailing address, telephone number, work unit, occupation, date of person, date of recording, person who stated the medical history, and degree of reliability

If the person stating the medical history is not the person himself, the relationship with the patient should be indicated.

Age: adult - one year old, infant - months, newborn - days

Address: Rural Area - Group, City - House Number

Admission time, recording time - minutes

Be flexible in your inquiries

The patient feels the most significant pain or the most obvious physical signs, and the most important reason for the visit

Medical terminology, concise and chronological order

Do not use onset time (time period)

Do not use diagnostic terms (signs\symptoms)

Don't use dialect

The whole process of the patient's illness: development, evolution, diagnosis and treatment process

Onset and duration of illness

Main symptoms and characteristics

Causes and incentives

The development and evolution of the disease

accompanying symptoms

Diagnosis and treatment process

General conditions during the course of the disease

The patient’s past health status and diseases he or she has suffered from in the past

Be careful not to confuse it with a history of current illness

Peptic ulcer can be recorded in the current history of episodes over the years

Describe in chronological order

A series of direct questions and a final history collection

Each system asks about 2 to 4 symptoms, positive - comprehensive and in-depth questioning, negative - transition to the next system

social experience

Occupations and working conditions

habits and hobbies

History of travel

Reproductive history: pregnancy, number of births, number of artificial or natural abortions, presence of stillbirths, surgical deliveries, perinatal infections, family planning, and contraceptive measures

The health and disease status of parents, siblings, and whether there are genetic diseases

The immediate family members of the deceased asked about the cause of death and age