After exploring a patient’s chief complaint, their current and past medical histories are reviewed to obtain a full understanding of their “human response” to medical conditions and life processes. While obtaining this information, it is also helpful to determine their understanding of the condition and its associated treatment. If a patient has a prior medical diagnosis, but is unaware of what it means or does not understand the recommended treatment, they may not be following instructions intended. For example, a patient diagnosed with “high blood pressure” may erroneously think they only need to take their medications when they feel as if their blood pressure is high, instead of daily at the recommended doses.
Categories included in past medical history include current health, medications, childhood illnesses, chronic illnesses, acute illnesses, accidents, injuries, and obstetrical health for females. Medication reconciliation is a comparison of a list of current medications with a previous list and is completed at every hospitalization and clinic visit. Not all categories of current and past health histories apply to every patient, so only ask questions that are relevant to the patient you are interviewing. See Table 2.6 [1] for suggested focused interview questions related to current and past medical history.
Table 2.6 Sample Focused Questions for Current and Past Health History
Are there any other issues affecting your current health or the ability to complete your daily activities?
Do you take your medications as prescribed?
When did they occur? Were you hospitalized?
When were you diagnosed?
Do you see a specialist for this chronic illness? If so, what is their name and location?
How is this condition currently being treated?
How has the chronic illness affected you? How do you cope with the illness?
Have you had any accidents or injuries?
Are you pregnant now or is there any chance of being pregnant now?
A comparison of a list of current medications with a previous list and is completed at every hospitalization and clinic visit.
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