Walking Through the Encounter

This is a general guideline on how to conduct a patient interview

Introduction

Hello Mr./Ms.__________
I am (name), (identify level of training)
I would like to spend some time with you gathering information about your health,(request permission)

Opening

How can I help you today OR What brings you in today?
Can you tell me a little more about your problem?

Specific Details to Assess

Onset
- When did it start?
Context
- What was happening when you first noticed the problem?
Location
- If there is a pain symptom, or a symptom with a particular location
Radiation
- If there is a pain, to where does it move or spread?
Character
- Describe what the symptoms are like
Timing and Duration
- When does it happen?
- How long does it last?
Severity / Intensity
- How intensive are the symptoms?
Modifiers
- What makes this better?
- What makes this worse?
Associated symptoms
- Anything else going on?

Past Medical History

Current medical problems
Prior illnesses
Prior surgery
Current medications
Allergies
Exposure history
- Work or environmental
Preventative health care
- Doctor visits, dental care

Family History

Age, living status and health questions related to:

Father / Mother
Siblings
Children
Other family members

Social History

Living arrangements
- Where and with whom
Relationship / marital status / partner
Education / occupation
Social stressors
Substance use:

(Current / past / what and how much)

Tobacco
Alcohol
Drugs

Review of Systems "Cheat Sheet"

General

Any fever, chills or night sweats?
Have you gained or lost a lot of weight without trying lately?
Have you felt unusually tired or sleepy lately?

Skin

Any area of skin dry and/or itchy?
Any rashes, bumps, sores anywhere
Do you bruise easily?
Any moles that are changing in shape, color, or size?
Any changes in your hair? Any changes in your nails?

Head

Have you been dizzy or feel like the room is spinning?
Have you fainted or passed out recently?
Do you have headaches? Are they more/less frequent than normal?
Any history of head injury?

Eyes

Have you had any problems with your eyes lately? Like blurry vision, pain, watery eyes, redness, or itching?
How is your vision?
Do you wear glasses?
Do you wear contact lenses?