Methods of Medical History Inquiry
1. General Information
General information includes: name, gender, age, marital status, ethnicity, occupation, place of origin, workplace, current address, etc.
Chief Complaint
The chief complaint is the most distressing symptom, sign, and duration reported by the patient during the visit. For example, “palpitations for 3 days, worsened with chest pain for 1 day.”
Points to Note:
1. The chief complaint must be accurately captured; the patient’s statements may be disorganized and lack clarity, and there is generally only one or two main symptoms.
2. The location, nature, severity, and duration of the symptoms described in the chief complaint must be clearly inquired about, avoiding vague or ambiguous language.
3. Generally, diagnostic names or test results should not be used as the chief complaint (e.g., “chronic gastritis” should not be used as a chief complaint if the gastroscopy shows chronic gastritis).
4. The chief complaint should be concise, generally less than 20 words.
General information and the chief complaint have been provided, so no further inquiry is needed.
2. Current Medical History6 points
Focus on the chief complaint, inquiring about the occurrence, development, changes, and treatment process of the disease from the onset to the current visit. Specifically inquire about the following:
1. Causes and Triggers of Onset: Inquire about the specific time of onset, mode of onset, any triggering factors, initial symptoms and their characteristics, and any treatments undertaken at the onset. List in points.
2. Course of the Disease: Inquire about the changes in the patient’s condition from the onset to the current visit, understanding the evolution and development trend of the disease, generally in chronological order, including any prodromal symptoms before onset, symptoms appearing at certain stages after onset, changes in nature and severity, when symptoms worsened or improved, when new symptoms appeared, and whether there are any patterns in the changes, such as diurnal variations, worsening symptoms in the afternoon, or changes after consuming greasy or cold foods, and how the condition alleviates, such as how long after taking medication or resting the symptoms improve, and any accompanying symptoms. List in points.
3. Treatment History: Inquire about the diagnoses and treatments the patient has received from the onset of the disease to the current visit, in chronological order. For example, what examinations were performed, what were the results; what diagnoses were made; what treatments were undertaken, and what were the effects and responses, etc. List in points.
4. Current Symptoms: Inquire about the symptoms the patient feels during the visit, such as temperature, sleep, diet, and bowel habits. List in points.
3. Past Medical History1 point
Inquire about the patient’s general health status, past illnesses (mainly asking about common diseases such as hypertension, diabetes, coronary heart disease, cerebrovascular diseases, etc., and infectious diseases such as tuberculosis, hepatitis), surgical history, blood transfusion history, trauma history, vaccination history, etc.
4. Personal Lifestyle History1 point
Inquire about the patient’s personal life experiences, mental and emotional state, dietary habits, smoking, drinking, or other habits, as well as daily routines, marriage, and childbirth.
(1) Life Experiences: Inquire about the patient’s place of birth, current and past living locations, etc.
(2) Mental and Emotional State: Inquire about the patient’s usual mental, psychological, and emotional state, such as being cheerful, anxious, depressed, irritable, or fearful.
(3) Dietary Preferences: Inquire about the patient’s usual dietary preferences, such as a preference for sour, sweet, or spicy foods.
(4) Daily Routines: Inquire about the patient’s daily habits, etc.
(5) Marital Status: Inquire whether the patient is married or cohabiting, and if necessary, inquire about sexual activity. Attention should be paid to protecting the patient’s privacy.
(6) Menstrual and Reproductive History: For women, inquire about the age of menarche or menopause, menstrual cycle, duration of menstruation, amount, color, and quality of discharge. For married women, also inquire about the number of pregnancies, births, and any history of miscarriage, premature birth, or difficult labor.
5. Family History1 point
Inquire about the health and illness status of the patient’s parents, siblings, children, and others closely related to the patient, such as spouses or cohabiting partners, including the causes of death of direct relatives.
6. Allergy History1 point
Mainly inquire about allergies to any medications or foods.
2. Inquiry Methods for Critically Ill Patients
For emergency or critically ill patients, focus on the main symptoms and conduct brief inquiries, emphasizing examination to save time for rescue and treatment. After the condition stabilizes, detailed inquiries can be conducted; do not delay treatment or rescue due to mechanical insistence on complete records.
3. Inquiry Methods for Follow-up and Referral Patients
For follow-up patients, focus on inquiring about changes in the condition after medication. Some patients with chronic conditions may have already undergone diagnosis and treatment before the visit; if treated at another hospital, further inquiries should be made about previous examinations, results, diagnoses, treatments, and efficacy.
4. Inquiry Methods for Special Patients
When patients have special circumstances, such as anxiety and depression, psychiatric patients, disabled patients, those with low educational levels or language barriers, critically ill patients, the elderly, or children, appropriate comfort, encouragement, inspiration, and guidance should be provided based on the specific situation of the patient during the inquiry. If necessary, accompanying personnel should assist in providing the medical history. The inquiry should promptly verify any unclear or questionable content in the patient’s statements, such as the timing of the condition, certain symptoms, and examination results, to improve the authenticity of the medical history.
5. Points to Note
1. Suitable Environment: Doctor-patient communication requires a quiet and comfortable examination room environment, which is conducive to both the doctor’s diagnosis and treatment and allows the patient to fully describe their condition. For certain conditions that are inconvenient to discuss in public, inquiries should be conducted privately or through one-on-one physical examinations.
2. Kind Attitude: Doctors should pay attention to gaining the patient’s trust, maintaining a kind attitude, and avoiding artificial barriers between the doctor and patient, while also being attentive to listening during conversations.
3. Simple Language: During the inquiry, the doctor’s language should be simple and easy to understand, avoiding the use of medical terms that the patient may not understand, such as Shaoyang disease, heat accumulation, etc. Regarding the patient’s condition, avoid expressions of surprise to prevent causing adverse stimulation to the patient and increasing their mental burden.
4. Avoid Suggestion: When the patient’s description of their condition is not clear or comprehensive, the doctor can provide appropriate guiding prompts, but should not suggest or induce the patient to describe their condition based on their own subjective intentions.
Symptom Inquiry
For symptoms appearing in the chief complaint, detailed descriptions should be provided in the current medical history. Below are common methods for inquiring about symptoms.
Can be remembered using the Ten Questions of Traditional Chinese Medicine:
1. Inquiry about Cold and Heat
1. If the patient has cold symptoms, ask whether they feel aversion to wind, cold, or fear of cold.
2. If cold and fever occur simultaneously, ask which is more severe, the aversion to cold or the fever.
3. If there is cold without fever, ask whether it is a new illness with aversion to cold or a chronic illness with fear of cold.
4. If there is heat without cold, ask whether it is a high fever, tidal fever, or low fever.
5. If there are alternating cold and heat symptoms, ask whether the alternation is regular or irregular.
2. Inquiry about Sweating
1. Special sweating: Ask whether it is spontaneous sweating, night sweats, absolute sweating, or battle sweating.
2. Localized sweating: Ask whether sweating occurs on the head, half of the body, palms and soles, chest, or genital area.
3. Inquiry about Pain
1. Nature of pain: Ask whether it is distending pain, stabbing pain, cold pain, burning pain, aching pain, cramping pain, empty pain, dull pain, wandering pain, fixed pain, or pulling pain.
2. Location of pain: For example, for headache, ask whether it is frontal pain, pain on both sides of the head, pain on the top of the head, or pain at the back of the head.
4. Inquiry about Head, Body, Chest, and Abdomen
1. Dizziness: Ask whether dizziness is accompanied by head swelling, headache, heaviness in the head, lightness in the feet, or tinnitus.
2. Chest tightness: Ask whether it is accompanied by palpitations, shortness of breath, cough, or breathlessness.
3. Palpitations: Ask whether it is accompanied by chest pain, chest tightness, shortness of breath, fearfulness, irritability, or dizziness.
4. Rib distension: Ask whether it is accompanied by irritability or fullness between the ribs.
5. Epigastric fullness: Ask whether it is accompanied by belching, acid regurgitation, reduced appetite, dry heaving, or a splashing sound in the epigastric area.
6. Abdominal distension: Ask whether abdominal distension is intermittent and relieved by pressure, or persistent and resistant to pressure.
7. Heaviness in the body: Ask whether there is a feeling of heaviness in the body.
8. Numbness: Ask whether there is numbness of the skin or limbs.
9. Fatigue: Ask whether fatigue is significant after activity.
5. Inquiry about Ears and Eyes
1. Tinnitus and deafness: Ask whether the tinnitus is loud at first and then gradually decreases.
2. Dizziness: Ask whether the patient feels that objects are rotating or if there are flying insects in front of their eyes.
3. Blurred vision: Ask whether vision is unclear or if it is unclear at dusk.
6. Inquiry about Sleep
1. Insomnia: Ask whether it is difficult to fall asleep, easy to wake up after sleeping, difficult to fall back asleep after waking, waking up startled, or restless during sleep.
2. Hypersomnia: Ask whether there is drowsiness, sleepiness after meals, sleepiness after a major illness, or extreme fatigue.
7. Inquiry about Diet and Taste
1. Thirst and drinking: Ask whether the patient feels thirsty and wants to drink water, or feels thirsty but does not want to drink.
2. Appetite and food intake: Ask whether there is a decrease in appetite, aversion to food, excessive hunger, lack of desire to eat, or food retention.
3. Taste: Ask whether the mouth is bland, sweet, sticky, sour, astringent, bitter, or salty.
8. Inquiry about Bowel Movements
1. Abnormal bowel frequency: Ask whether there is constipation or diarrhea.
2. Abnormal stool quality: Ask whether the stool is undigested, loose, contains pus or blood, or has blood in it.
3. Abnormal bowel sensation: Ask whether there is a burning sensation in the anus, urgency, unsatisfactory bowel movements, fecal incontinence, or a feeling of heaviness in the anus.
9. Inquiry about Urination
1. Abnormal urination frequency: Ask whether there is frequent urination or urinary retention.
2. Abnormal urine volume: Ask whether there is increased or decreased urine volume.
3. Abnormal urination sensation: Ask whether there is pain in the urethra, incomplete urination, urinary incontinence, or enuresis.
10. Inquiry about Menstruation
1. Abnormal menstrual cycle: Ask whether menstruation is early, late, or irregular.
2. Abnormal menstrual volume: Ask whether there is excessive or insufficient menstrual flow, or abnormal uterine bleeding.
3. Dysmenorrhea: Ask whether there is pain before, during, or after menstruation, and the nature of the pain.
11. Inquiry about Vaginal Discharge
Ask about the color, texture, and quantity of the discharge.
12. Inquiry about Males
Ask whether there is impotence, nocturnal emission, or premature ejaculation.
13. Inquiry about Children (Newly Added in 2020)
Ask whether the child has been ill, what medications have been taken, the mode of delivery, feeding methods, nutritional status, vaccination history, infectious disease history, causes of illness, and family history of hereditary diseases.
For different age groups of children, focus on different content.
14. Inquiry about Emotion-Related Symptoms (Newly Added in 2020)
Inquire about the patient’s subjective experiences related to emotions, combined with observations of the patient’s facial expressions, posture, actions, and the tone and volume of their speech, to determine whether the patient exhibits abnormal emotional changes such as depression, elevated mood, anxiety, fear, irritability, or restlessness.
Previous Recommendations
-
91 Diagnostic Formulas for Chinese and Western Medicine Skills Examination
-
Traditional Chinese Medicine Written Examination Points Sharing (1)
-
Traditional Chinese Medicine Written Examination Points Sharing (2)
-
Traditional Chinese Medicine Written Examination Points Sharing (3)
-
Traditional Chinese Medicine Written Examination Points Sharing (4)
-
Follow us on WeChat for more materials
-
WeChat: 18983897328