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medical history

 

Definition: a narrative or record of past events and circumstances that are or may be relevant to a patient's current state of health. Informally, an account of past diseases, injuries, treatments, and other strictly medical facts. More formally, a comprehensive statement of facts pertaining to past and present health gathered, ideally from the patient, by directed questioning and organized under the following heads. Chief Complaint (CC): a brief statement of the complaint or incident that prompted medical consultation. History of Present Illness (HPI): a detailed chronologic narrative, as much as possible in the patient's own words, of the development of the current health problem from its onset to the present. Past Medical History (PMH): prior illnesses, their treatments and sequelae. Social History (SH): marital status, past and present occupations, travel, hobbies, stresses, diet, habits, and use of tobacco, alcohol, or drugs. Family History (FH); present health or cause of death of parents, brothers, sisters, with particular attention to hereditary disorders. Review of Systems (ROS): an exhaustive survey of symptoms or diseases, organized by body system, not covered in previous parts of the history.

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© Copyright 2017 Wolters Kluwer. All Rights Reserved. Review Date: Sep 19, 2016.
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