History Taking — Complete Guide

Structure of every history

Section	What to cover	Priority
PC	Presenting complaint — one sentence in patient's own words	Must
HPC	Full exploration — SOCRATES for pain, timeline, associated symptoms	Must
PMH	Previous illnesses, operations, admissions. MJT = MI, Jaundice, TB	Must
Drug History	Medications (name, dose, frequency), OTC, herbal, allergies + reaction type	Must
Family History	First-degree relatives, relevant conditions	Important
Social History	Occupation, smoking, alcohol, drugs, home, support, ADLs, travel	Must
Systems Review	Brief screen of systems not covered in HPC	Important
ICE	Ideas, Concerns, Expectations — always explore	Must

Key frameworks

SOCRATES

For any pain or symptom

Site — where exactly is it?

Onset — sudden or gradual? doing what?

Character — sharp, dull, burning, crushing, colicky?

Radiation — does it spread anywhere?

Associated symptoms — nausea, SOB, sweating?

Timing — constant or intermittent? how long?

Exacerbating/Relieving — what makes it better or worse?

Severity — out of 10? worst ever?

ICE

Patient-centred care — always ask

Ideas — "What do you think might be causing this?"

Concerns — "Is there anything specific you were worried about?"

Expectations — "What were you hoping we could do for you today?"

Explore naturally during the consultation — not as a formal checklist at the end.

CAGE

Screening for alcohol dependence

Cut down — ever felt you should cut down on drinking?

Annoyed — people criticised your drinking?

Guilty — ever felt guilty about drinking?

Eye opener — needed a drink first thing in the morning?

≥2 positive = alcohol dependence likely. Further assessment needed.

HEEADSSS

Adolescent / paediatric psychosocial history

Home — living situation, family relationships

Education/Employment — school, plans

Eating — diet, body image, weight concerns

Activities — hobbies, sports, social life

Drugs — tobacco, alcohol, recreational drugs

Sexuality — relationships, sexual health (sensitively)

Suicide/Depression — mood, self-harm, suicidal ideation

Safety — abuse, bullying, violence at home

OLDCARTS

Alternative to SOCRATES

Onset

Location

Duration

Character

Aggravating factors

Relieving factors

Timing

Severity (0-10)

4Ps — Social History

Never forget these

Profession — current and past (exposure history)

Pack-years — cigarettes/20 × years smoked

Pints (alcohol) — units/week; CAGE if indicated

Partner/Home — living situation, support, dependants

Drug History

Always ask about all of these

•

Prescribed medications — name, dose, frequency, adherence

•

Over-the-counter (OTC) — paracetamol, NSAIDs, antihistamines

•

Herbal / traditional remedies

•

Contraceptive pill / HRT

•

Allergies — what to? what was the reaction?

•

Recent changes or new prescriptions

Closing the Consultation

Always end with

"Is there anything else you wanted to mention?"

Summarise back to the patient — checks accuracy and rapport

Explain the next steps clearly

Check understanding — "Does that make sense?"

Thank the patient

Universal Red Flags — Always Explore

Unexplained weight loss

Night sweats

Haemoptysis

Haematemesis / malaena

Rectal bleeding

Dysphagia

Change in bowel habit

New neurological deficit

Thunderclap headache

Bladder/bowel dysfunction

Bone pain at rest

Unexplained fever >38.5°C

⚠ These frameworks support, not replace, full clinical training. Always adapt to the individual patient and clinical context.

🩺 History Taking