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Chronic Illness History

From Mediwikis

Note that history taking from any patient should be tailored to their situation, this is just a list of important areas to cover.

Build Rapport

  • Introduce self
  • Gain consent
  • Smile :-)

Problem List

  • What are your current medical problems?
    • What are your beliefs about this condition?
  • Which one of those is most important to you? or If you could get rid of just one of the things you mentioned, which would it be?
  • How did it start? How long ago was that?
    • What did you think it was? Was there anything you were worried it might be?
    • How did it feel to be diagnosed?
  • What are you like now?
  • Have the health professionals been supportive through your disease career?
  • Appropriate to ask some screening questions here relevant to system
  • How do you expect your condition to change in the future? How does that make you feel?
    • What are the obstacles to your normal care?

Social History

  • What impact has your condition had on your life?
    • e.g. Cooking, cleaning, housework, going out, looking after pet, seeing family/friends, driving, shopping.
    • Respond to impact appropriately
  • What kind of house do you live in? e.g. residential home, house with stairs.
  • Who's at home for you? Do you look after them, do they look after you, or are you both independent?
  • Do you have any adaptations to your house to help you day to day?
    • Do they make a big difference?
  • Do you work?
    • How has the condition affected your job?
    • Has your job affected the condition?
  • Do you get out of the house? Drive? Any adaptations: Sticks, Zimmer, Scooter.
  • Smoking & Alcohol
    • Have you thought about cutting down?

Drug History

What medications do you take?

  • Do they help?
  • Do you have any side effects?

Do you have any allergies?

Family History

Are there any conditions that run in your family? Have they had anything similar to you?

  • How do they do with it? How does that make you feel?

Do you care for your family or do they care for you?

Others

Past Medical History- other conditions, how the multiple conditions affect one another.