The General History

Written by Dr.Md.Redwanul Huq (Masum)
Sunday, 23 December 2012 01:26

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).


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

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