COMPLETE HISTORY (HPI, PMH, HEALTH MAINTENANCE, FH, SH)
ESSENTIALS OF CLINICAL SKILLS
Not Done Incomplete Done
Desired Behavior
General Medical Etiquette, Communication, Identifying Information
Introduce him/herself to the patient
State  first and  last name
 State full title (1st year medical student)
Demonstrate attention to clean technique
 Wash hands before patient contact,  all hand surfaces,  for 30 seconds
Re-wash as needed  No  Yes  Not applicable
Elicit information about patient’s  preferred language
Explain purpose of encounter and student role
 Purpose of encounter (gather some information for now, later will also perform a
limited exam),
 Student role (take info to doctor, doctor will decide care plan with you)
Obtain and record patient’s  full name and  age (inquiry) and observe apparent
gender (observation recorded in note);  address patient formally
Utilize rapport skills: nonverbal SOFTEN
 Smile,  Open body,  Forward lean,  Touch,  Eye contact,  Nod
Utilize rapport skills: verbal PEARLS statements
 Partnership,  Empathy,  Apology,  Legitimation,  Respect,  Support
Communicate clearly:  Avoid jargon (or give explanation of terms after use)
 Avoid leading questions
Use summarization for verification, clarification, or elaboration of information.
 Invite patient to correct information,  review at least 4 history items with patient
Chief Complaint
Elicit the  Chief Complaint (record VERBATIM in quotes) and
Identify  ALL agenda items.
History of Present Illness
Elicit  bodily location AND  radiation of symptom
Elicit quality of symptom
Elicit quantity/severity of symptom
Elicit timing:  onset,  duration,  frequency, and  progression over time
Elicit setting/context of symptom at time of onset
Elicit  ALL  aggravating factors
Elicit  ALL  relieving factors
Elicit associated symptoms and/or pertinent negatives
 Start with an open-ended question,  ask “anything else?” until “no”, then
 Ask 3 additional specifics appropriate for the chief complaint
Elicit whether patient has ever had similar symptoms before
Elicit patient's ideas, hypotheses/theories about cause(s) of symptoms/condition
Elicit patient's worries/fears about cause(s)/implications of symptoms/condition
Elicit impact of symptoms/condition on one or more of the following:
 daily functioning,  relationships, or  self-concept
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Past Medical History and Health Maintenance
Elicit information about the patient’s general state of health. Ask an open-ended
question and then use scale (patient rates health as excellent, very good, good, fair, or
poor).
Elicit information about significant medical diseases/ conditions as an adult.
 Start with an open-ended question, then 5 specifics from the following list:  HTN, 
heart disease,  stroke,  lung disease,  DM,  cancer,  obesity,  depression, 
dementia.
Elicit information about significant psychiatric diseases/ conditions.
Elicit PHQ-2 (2 items, asked VERBATIM):
 Over the past 2 weeks have you often been bothered by feeling down, depressed or
hopeless?
 Over the past 2 weeks, have you often been bothered by little or no pleasure in
doing things?
Elicit information about all current prescription medications including  dosage,
 frequency,  indication,  effectiveness, and  side-effects for each.
Elicit information about all non-prescription drugs:  over the counter medications
AND  vitamins, supplements, home/folk remedies including  dosage,  frequency, 
indication,  effectiveness, and  side-effects for each.
Elicit information about all  previous allergies—particularly allergies to medication—
AND  specific reaction that occurred.
Elicit information about all previous hospitalizations, identifying  indications and 
dates (or age) of those hospitalizations.
Elicit information from women about  menstrual history (age of onset, current
problems, menopause) AND  pregnancies (number, outcomes).
Elicit information (action, frequency, results) about at least 3 preventive/screening
practices. For women must include:  pap smears and  mammograms. For 50+: 
fecal occult blood testing for colon cancer and  colonoscopy
Elicit information about current immunization status: specifically ask about  tetanus,
 hepatitis B and  influenza; AND for diabetic or geriatric (>65 years old) patient, also
ask about  pneumonia and  shingles vaccines.
Family History
Elicit information about any blood relatives having illness/ condition with features
similar to patient’s current illness/condition; if YES identify relationship.
Elicit general information about the  age (now or at time of death) and  health
status of all 1st degree blood relatives representing at least 3 generations:
grandparents, parents, siblings, and children
Elicit specific information about any diseases that tend to run in his/her family.
 Start with an open-ended question, then ask specifically about at least 5 of the
following:  HTN,  heart disease,  stroke,  lung disease,  DM,  cancer, 
obesity,  depression,  dementia.
Personal and Social History
Elicit information about the patient's  education level.
Elicit information about  relationship status AND  living situation (household
members, environment, pets).
Elicit information about the patient's  current AND  former occupations AND
associated  hazards/risks. Ask about  military service.
Elicit information about adequate  financial resources for  food,  shelter, and
 medical care.
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Elicit information about tobacco use—  current AND  past use—AND  attempt to
quantify the amount of use.
Not Done
Incomplete
Done
Elicit information about alcohol use—  current AND  past use—AND  attempt to
quantify the amount of use.
Elicit information about recreational drug use—  current AND  past use—AND
 attempt to quantify the amount of use.
Elicit information about gender identity and sexual activity— [] gender identity
[] sexual orientation  number of current and  past partners
Elicit information about usual dietary practices.
Elicit information about the presence of a support system for illness and/or
emotional upset.
Elicit information about at least 3 patient safety practices—including:  seat belts, 
smoke detectors,  sun screens/sun protection,  presence of weapons in house and
if so, are the weapons unloaded and locked.
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