Comprehensive Health History Assignment

Initiating the session [Joining stage]

• Greet patient appropriately (including verification of name)
• Introduces self, role and nature of the interview
• Gains verbal consent
• Ensures patient is comfortable and ready for the interview
• Asks the patient what brings them in today [chief complaint]
• Listens attentively, leaving the patient space to think before answering
• Confirms the patient’s concerns and screens for any further problems

Gathering Data [Working stage]

1. Returns to the main concern [chief complaint] and elicits the following information:

• What caused the problem
• What is worrying them the most
• What are they hoping to get out of this interview/visit
• How is the presenting complaint effecting their life

2. Elicits history of present illness including:

• Location, quality / character, quantity / severity
• Timing (onset, duration & frequency)
• Aggravating and alleviating factors; associated symptoms

3. Establishes current medications
4. Identifies allergies – medication, foods, pollens, tapes
5. Elicits past medical and surgical history
6. Elicits family history
7. Elicits current social habits and past social history
8. Elicits a complete review of systems

Humanistic and professional skills [Interview technique]

• Shows respect and empathy
• Listens attentively, leaving the patient space to think before answering
• Interviewer posture conveys interest
• Interviewer free of inhibiting mannerisms
• Facilitates patient’s responses through verbal and nonverbal encouragement such as silence,
• paraphrasing, nodding of the head
• Clarifies patient’s statements
• Periodically summarises pertinent information for patient
• Adapts to patient’s level of understanding (avoid / explain jargon)

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