Examiner Link Copied!
Clinical Guide
ADULT HISTORY TAKING MANUAL
A Comprehensive Clinical Guide for Medical Students and Practitioners
About This Manual
This manual provides a concise, structured framework for taking and recording a comprehensive adult medical history. It is designed to help medical students, interns, and clinicians ensure that no key aspect of patient assessment is missed and that history taking remains systematic, efficient, and clinically focused.
Includes:
- Standardized Adult History Template
- Headings and Subheadings for Each Section
- Exact Dialogue Scripts (What to ask)
Edition: 2026 Clinical Format Version
Prepared by: Dr. Raheel Azhar
Comprehensive Adult History Taking Manual
1
Pre-Consultation & Introduction:
What to say
"Good morning, I am Dr. [Name], one of the doctors today. Could I confirm your full name and date of birth, please? I have been asked to take your history today to better understand what's been happening."
Knock, enter, wash hands, and ensure a respectful approach before beginning.
2
Verbal Consent
What to say
"Would it be alright if I ask you a few questions about your symptoms?"
3
Confidentiality
What to say
"Everything we discuss today will remain strictly confidential within the medical team looking after you."
4
Presenting Complaint (PC)
What to ask
"What has brought you in to see me today?" OR "Can you tell me what's been going on?"
(Allow the patient to explain freely for 30-60 seconds before interrupting to narrow down.)
5
History of Presenting Complaint (HPC)
What to ask (For Pain)
"Where exactly is the pain? When did it start? What does it feel like—is it sharp or dull? Does it spread anywhere? What makes it better or worse? On a scale of 0 to 10, how bad is it?"
What to ask (For Non-Pain)
"When did this start? Did it come on suddenly or gradually? How often does it occur? Have you noticed any other symptoms like a fever or weight loss?"
A. If Pain Is the Complaint-> Use SOCRATES
- Site - Where is the pain?
- Onset - When did it start?
- Character - What does it feel like? (sharp/dull/burning)
- Radiation - Does it spread anywhere?
- Associated symptoms - Any vomiting, fever, or rash?
- Time course - Constant or intermittent?
- Exacerbating/relieving factors - What makes it better or worse?
- Severity - On a scale of 1-10, with 10 being the worst pain imaginable, how bad is it?
B. If non-pain symptom (e.g., cough, diarrhoea)
Use Structured Symptom Analysis
- Onset: Sudden vs gradual.
- Course/Duration: Constant vs intermittent.
- Severity/Quantity: Frequency or amount (e.g. sputum, stool).
- Character: e.g. Dry/productive cough, watery/bloody stool.
- Associated Symptoms: Fever, weight loss.
- Exacerbating/Relieving: What makes it better/worse.
Relevant Negatives (Rule Out Serious Causes)
- Ask targeted red flags depending on symptom (e.g., haemoptysis in cough, blood in stool in diarrhoea)
- Include: Impact on daily life (e.g., "How has this affected your usual activities?").
"SOCRATES is for pain. Everything else needs symptom-specific thinking."
6
Ideas, Concerns, and Expectations (ICE)
What to ask
"What do you think might be causing your symptoms?Is there anything in particular that's worrying you the most?
What were you hoping we might do for you today?"
(This shows empathy, patient-centred communication, and insight.)
7
Past Medical History (PMH)
What to ask
"Do you have any medical conditions, such as diabetes, high blood pressure, or heart disease? Have you ever been admitted to the hospital?"
8
Past Surgical History (PSH)
What to ask
"Have you had any previous operations or procedures? Were there any complications with the surgery or the anaesthesia?"
9
Medication History
What to ask
"Are you taking any prescribed medications at the moment? Any over-the-counter tablets or herbal supplements? Have there been any recent changes to your doses?"
10
Family History
What to ask
"Are there any medical conditions that run in your family, like heart disease, cancer, or diabetes? Are your parents still alive?"
11
Allergy History
What to ask
"Do you have any allergies to medications, food, or anything else? What exactly happens when you have a reaction?"
12
Social History
What to ask
"What kind of work do you do? Do you drink alcohol or smoke? Who do you live with, and how are you managing at home with these symptoms?"
13
Travel History
What to ask
"Have you travelled anywhere recently, either in the UK or abroad? Did you take any necessary vaccinations or malaria tablets before you went?"
14
Systemic Review
What to ask
"Before we finish, have you noticed any unexplained weight loss, fevers, or night sweats? Any chest pain, shortness of breath, or changes in your bowel habits?"
Screen other body systems briefly for associated or alternative pathology.
15
Patient's Additional Input
What to ask
"Is there anything else you'd like to mention that we have not discussed today?"
(Always offer the patient a final opportunity to contribute; OSCE examiners value this.)
16
Summary
What to say
"To summarize, you are a [age]-year-old presenting with [symptom] that has been ongoing for [duration]. Does that sound accurate to you?"
17
Safety Netting & Follow-up
What to say
"If your symptoms get significantly worse, or you develop [specific red flag], please seek immediate medical attention or go to A&E. If there is no improvement, please book a follow-up with us."
History-Taking Flow
01 Introduction
02 Consent
03 Confidentiality
04 PC
05 HPC
06 ICE
07 PMH
08 PSH
09 Medications
10 Family Hx
11 Allergies
12 Social Hx
13 Travel
14 Systemic Review
15 Final Additions
16 Summary
17 Safety Net
OSCE Pacing Challenge: Red Flag Injections
Read the clinical vignette, verbalize your "must-not-miss" red flag questions out loud, and then click to reveal the examiner's checklist.
Scenario 1: "A 45-year-old woman presents with a sudden, severe headache that started an hour ago. She describes it as the worst headache of her life."
- Neck stiffness / Photophobia: (Checking for meningitis or subarachnoid hemorrhage)
- Fever / Rash: (Checking for meningococcal disease)
- Weakness / Numbness / Speech changes: (Checking for focal neurological deficits/stroke)
- Vomiting / Worse bending over: (Checking for raised Intracranial Pressure)
Scenario 2: "A 68-year-old man presents with lower back pain that has been worsening over the last month. The pain is worse at night and wakes him from sleep."
- Unintentional weight loss / Night sweats: (Checking for malignancy/infection)
- Bowel or bladder incontinence: (Checking for Cauda Equina Syndrome)
- Saddle anaesthesia (numbness around the groin): (Checking for Cauda Equina Syndrome)
- History of previous cancer: (Checking for metastases)
Scenario 3: "A 55-year-old man presents with a persistent cough for the last six weeks. He is a smoker of 30 pack-years."
- Haemoptysis (Coughing up blood): (Checking for lung cancer or TB)
- Unintentional weight loss / Loss of appetite: (Checking for malignancy)
- Night sweats / Fever: (Checking for Tuberculosis/Lymphoma)
- Shortness of breath / Chest pain: (Checking for cardiopulmonary collapse/mass effect)
Live Session Score
0 / 17
History-Taking Flow
01 Introduction
02 Consent
03 Confidentiality
04 PC
05 HPC
06 ICE
07 PMH
08 PSH
09 Medications
10 Family Hx
11 Allergies
12 Social Hx
13 Travel
14 Systemic Review
15 Final Additions
16 Summary
17 Safety Net