patienthistory

Patient history, or medical history, is the systematic collection of information about a patient’s past and present health status, experiences, and factors relevant to current care. It is a core component of clinical assessment and supports diagnostic reasoning, risk assessment, and treatment planning. A well-taken history helps to establish a baseline for ongoing care and informs decisions about testing, referrals, and preventive measures.

Typical elements include the chief complaint and history of present illness, past medical and surgical history, current medications and allergies, immunization status, family medical history, and social history such as tobacco, alcohol, drug use, sexual activity, living situation, and occupational exposures. A review of systems may be performed to detect symptoms not yet volunteered. Information is gathered through patient or caregiver interviews and documented in electronic or paper records using standardized formats.

The history is kept confidential and is subject to professional, legal, and ethical standards for privacy and consent. Accurate documentation and clear communication support continuity of care, guide diagnostic testing, and inform preventive care. Clinicians may supplement or verify information as needed and consider language needs, health literacy, and cultural factors to optimize understanding and completeness.

Limitations include recall bias, omissions, language barriers, cognitive impairment, and time constraints. As a record in medical documents, patient history is dynamic and should be updated with new information or changes in health status during ongoing care.