How (and Why) to Give a Good Medical History

January 29, 2020

Mark L. Friedman, MD, FACEP, FACP

When it comes to your health, you and your doctor are a team. Your doctor has years of medical training, but you’re the authority on your personal and family health history.

This history is more important information than you might think. It:

  • Gives your doctor the context she needs to provide the correct diagnosis
  • Should always be accounted for when ordering lab tests, imaging, and other screenings
  • Saves you time by making your visit more efficient
  • Can save you money by avoiding unnecessary testing


Chief Complaint

Typically the doctor will start by asking an open-ended question like,  “What concerns you today?”

Go ahead and answer with your “chief concern” or major problem. Symptoms are extremely helpful, whereas a self-diagnosis (no matter how much Googling you’ve done) is counter-productive more often than not.

  • Helpful: “I’ve had 102-degree fever for two days. I’m coughing up thick brown phlegm, having shaking chills and feel weak and fatigued.”
  • Less helpful: “I have pneumonia.”

Related information like, “I am just getting over a four-day cold and am allergic to penicillin,”  is also useful. One or two sentences is perfect.

If you’re wondering how to best describe your symptom, below is what the doctor needs to know.

  • Severity
  • Location
  • Timing
  • What makes it better/worse

Take our example of pain: “I have a severe, dull/crampy pain in my upper-right abdomen. It radiates to my back just below the shoulder blade. It starts an hour after dinner and gets worse overnight. It’s gone in the morning.”

Additional Concerns

Now is a great time to mention any secondary health concerns you’d like to talk to your doctor about before the visit ends. These issues will be addressed after your chief complaint.


History of Present Illness

Next, the doctor will ask a series of questions about your chief complaint. Don’t overthink it — brief answers are best. At this point, feel free to volunteer related information such as, “The flu is going around my office.”


Past Medical History

During this portion of your visit, the doctor will ask some questions about your personal medical history. This is the time to mention related or major issues. For this example, let’s say your chief complaint is abdominal pain.

  • Helpful: ”I had an appendectomy six months ago.”
  • Helpful: “I’ve changed my diet and am also taking a new medication.”
  • Less helpful: “I’m allergic to cats.”

Be sure the doctor has your complete list of medications and medication allergies. These might be a clue to diseases you may not think to mention, or help the doctor rule out prescriptions you might have a bad reaction to.

Family History

The doctor is looking for clues based on inheritance or association. For example: In the case of chest pain, did your father have a heart attack? What significant diseases run in the family? Diabetes? Hypertension?


Personal and Social Life

If you have a sore throat, the fact that your significant other just had a positive strep swab is important. Always remember that your doctor is trying to help you, not judge you. Be open about sensitive topics like smoking, alcohol or drug use, and sexual activity.


Review of Systems

If you’re in for your annual physical, the doctor will ask you questions about each body system (heart, lungs, kidneys, joints, nerves, and so on). If your visit is not a full physical, your doctor may focus on just one or two systems related to your chief complaint.


FSH Pro Tip

Bring notes! If you’re like most of us, you’ve gotten into the car after a doctor appointment and thought, “Shoot! I should have mentioned _________.” or “Ugh, I meant to ask about __________.” Bringing notes with you ensures you won’t forget! 

Take notes. Writing down the answers to questions and any instructions the doctor gives you will help you remember what to do and avoid confusion later on.


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Originally published Jan 29, 2020 3:23:09 PM.