The General History includes the following-

Particulars of the Patient:

• Name
• Age (Date of birth)
• Sex
• Religion
• Marital status
• Occupation
• Address (Temporary & Permanent)
• Date & Time of Admission (In In-Patient setting)
• Way of Admission (Through Outdoor or Emergency, In In-Patient setting) should also be included in general history

Presenting complaints (PC) / Chief complaints:

Chief complaints of the patient should be-

-A brief description having 3-4 complaints the chronology of which should be according to duration or severity,

– In the patient’s own words.

History of Present illness/presenting complaint (HPC):

•  Starts as *According to the statement of the patient/patient’s attendant (In case of unconscious patients or children) he/she was reasonably well…..(the duration) back, then he/she has developed…….(First symptom)……then-
• Elaboration of the presenting complaints.
• Query about associated symptoms
• Exclusion of different probable causes producing all or some of the symptoms- by asking the patient negative symptoms
• Asking about presence of any lifelong disease like Diabetes Mellitus, Bronchial Asthma, Hypertension etc is also important in history of present illness.

Past medical history (PMH)/ History of past illness/ History of previous illness:

Asking the patient about-

• Past medical problems, e.g. Myocardial infarction, Jaundice, Tuberculosis, Rheumatoid arthritis, Epilepsy, Stroke etc
• Past psychiatric Illnesses (Depression, Schizophrenia etc.)
• Previous operations (Appendicectomy, Cholecystectomy etc.)
• Previous hospitalizations
• Previous injuries.

Drug history

Drug history includes asking about-

• Current prescriptions (If present) (Including all doses and durations of drugs)
• Intake of over-the-counter drug(s)
• Intake of OCP, supplements, HRT (In case of female)
• Use of alternative medications
• Allergic or any other type of adverse reaction of drug(s).

Family history

•  Family members(How many & who are they) are significant to know in family history
• Relevant illness in family members(parents/ siblings/ children )
• The current complaint(s) in them,( health, cause of death, age of death etc.)
• Presence of any hereditary illness like Diabetes mellitus, Bronchil asthma,Hypertension etc.

Social history

• Living circumstances- house or hat or bungalow or flat
• Details about sanitation, type of drinking water, way & place of taking meal.
• Social history also includes Social habits (if present).

Personal history

Personal history includes-

• Date and place of birth
• Dietary habit
• Daily activities like washing, dressing, etc.
• Physical activity
• Level of education
• Smoking (If yes-type, number per day, total duration of intake)[1 pack year is equivalent of smoking 20 cigarettes/day for 1 year (e.g. if anyone smokes 20 cigarettes /day for 3 years, then he/she has a history of 3 pack years)]
• Alcohol (If yes-type, amount per day, total duration of intake).[As a rough calculation, an average pint of beer/standard glass of wine = 2-2.5units, alcopops = 1.5 units, a shot = 1 unit]
• Number and types of pets(If present)
• Foreign travel -place & way of living, any immunization/ prophylactic measurement before traveling (If relevant).

Occupational history

• Occupation (Present & past)
• Any exposure to hazardous agents.

Immunization history

•  Times & types of immunization.

Marital history

•  Marital status (including quality)
• Health of the spouse / children
• Sexual activity.

Sexual history

•  Sexually active/not
• Number of partners
• Any protective measure during sex
• Any difficulty during intercourse
• In case of male only-Painful erections (priapism), Abnormal bend on erection
• In case of female only- Contraception- on OCP/others, Pain during/after intercourse, Difficulty in conceiving, Pap smear- date & result of last smear’s also needed in sexual history.

Menstrual history (In case of female)

• Time of menarche
• Bleeding before puberty
• First day of last menstrual period (LMP)
• Length of menstrual cycles
• Length of menstrual period
• Regularity of periods
• Shortest and longest menstrual period
• Number of pads or tampons required during period
• Pain during periods
• Bleeding between periods
• Bleeding after intercourse
• If menopause-Time of onset, Presence of hot flushes, night sweating etc, Bleeding after menopause.

Obstetric history (In case of female)

• Number of children
• Age of the last child (ALC)
• Weights of children at birth
• Possibility of current pregnancy
• History of miscarriages and/or terminations (If present-time,cause,number)
• Problems during pregnancy (e.g. bleeding, abdominal pain,convulsions etc) or during delivery(e.g. prolonged labour, assisted delivery etc).

Summarizing

After taking the history, it’s useful to give the patient a summary of what he/she has told .