Format of the History

The information obtained by the interviewer is organized into a comprehensive statement about the patient's health. Traditionally, the history has been obtained by using a disease-oriented approach emphasizing the disease process that prompted the patient to seek medical advice. For example, a patient may present with shortness of breath; the interview would be conducted to ascertain the pathologic causes of the shortness of breath.

An alternative approach to obtaining the history is a patient-oriented one. This entails evaluating the patient and his or her problems more holistically. By using this approach, the health-care provider can elicit a more complete history, keeping in mind that other symptoms (e.g., pain from arthritis, weakness, depression, anxiety) may have an impact on the patient's shortness of breath. For example, if a patient has arthritis and cannot walk, shortness of breath may manifest as less severe than if the patient were able to walk and experienced shortness of breath with minimal activity. In this way, the entire patient is taken into account.

The major traditional sections of the history, with some patient-oriented changes, are as follows:

Source and reliability Chief complaint

History of the present illness and debilitating symptoms Past medical history Health maintenance

Occupational and environmental history Biographic information Family history

Psychosocial and spiritual history Sexual, reproductive, and gynecologic history # Review of systems

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