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The medical history represents the single-most important opportunity
to obtain individualized medical information. Since it is an opportunity and
not a guaranteed source of information, the caregiver or patient
during the interview may unknowingly miss critical data. Language
proficiency, patient and caregiver cognitive abilities, readiness
to change behavior, interest in seeking health care, and personal
comfort with the practitioner are only a few factors that may influence
the ability to obtain vital information. The information in this
chapter can enhance the health care provider’s ability
to obtain patient information and to delve more deeply into patient
motivation and understanding than the classically structured patient
history. It assumes that it is a caregiver of a patient that is being
interviewed, but the principles described apply to interviewing
patients when developmentally appropriate. A more detailed discussion
of communication approaches is provided in Chapter 3.
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Table 4-1 describes the traditional patient
history. The typical history focuses on gathering a variety of specific
information in a brief period of time. The very important information recorded
in the traditional history is an organized synopsis and a necessary
summary of medications, surgeries, and major medical events. The
degree of detail present in the various components is highly variable
and should be tailored in response to the purpose and duration of
the visit. The traditional history provides early valuable insight
into factors influencing a patient’s motivation for seeking care.
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The challenge of the medical history is to not lose sight of
the patient and caregiver’s often unstated goals. A significant
hazard of the traditional medical history is losing valuable information
that may not present itself if the patient feels overwhelmed with
a long list of simple closed-ended questions.1 Approaching
the medical history as a “laundry list” of simple questions
with simple, 1-word, or yes/no answers, the health care
provider will often prevent patients and caregivers from expressing
pertinent concerns and from identifying barriers to care. Often,
large parts of the medical history can be obtained from ...