A medical history typically follows the history of the present illness if obtained by the treating clinician. The medical history can reveal diagnosed medical conditions, past medical conditions, and potential future health risks for the patient. In addition, the medical history aids in forming differential diagnoses.
A comprehensive history intake includes the patient’s medical history, past surgical history, family medical history, social history, allergies, and medications. Within graduate education, the order of obtaining medical history generally follows the format below. However, with clinical experience, the clinician may follow a more colloquial, natural flow to the clinical intake. Some areas are omitted or expanded depending on the purpose of the medical history and healthcare setting. Some aspects of the medical history are standardized to arrive at an accurate differential diagnosis, leading to optimal patient outcomes. Members of the interprofessional team contribute to each aspect of the medical history intake. Health History is intended for our practicing clinicians to gain the big picture of your situation and then to adhere to the medical practices commonly employed in the United States.