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1
TEAM MEDICS: History Taking
2. History Taking
2-1. Chief Complaint/Concern
• "How can I help you today?"
• “Please tell me more about the (symptom).”
2-2. History of Present Illness (OPQRST)
• Onset
“When did you first notice the (symptom)?”
“When did the (symptom) start?”
“Did it start suddenly or gradually?”
• Provoking & Palliating factors
“What makes the (symptom) worse?”
“What makes the (symptom) better?”
• Quality
“Could you describe the (symptom)?”
“Is the pain sharp or dull?”
• Region & Radiation
"Could you show me where the pain is?"
"So the pain is located in (anatomical area), right?"
"Does the pain move anywhere else?"
• Severity
“On a scale of one to ten, ten being the worst pain you can imagine, how severe is the pain
now/when it started/( ) hours ago?”
"Is the pain getting better or worse?"
• Symptoms (relevant to differential diagnosis)
“Do you have (symptom: noun)?”
“Do you feel (symptom: adjective)?”
“Have you noticed any changes in (habit)?”
• Secretions (stools, urine, phlegm, nasal/vaginal/wound/eye discharge)
Color: "What color is the (secretion)?"
Appearance: “Could you describe the (secretion)?”
Amount: “Do you have a large amount of (secretion)?”
Frequency: “How often do you have the (secretion)?”
Odor: “Have you noticed any unusual smell in the (secretion)?”
Blood: “Have you noticed any blood in your (secretion)?”
• Timing
"How many hours/days/weeks have you had this (symptom)?”
“Does the (symptom) come and go or do you have it all the time?”
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TEAM MEDICS: History Taking
• Illness
"Have you ever had any serious health problems in the past?”
“Are you seeing a doctor for any other problems?”
• Trauma
"Have you ever had any major injuries in the past?”
• Surgery
“Have you ever had any surgeries in the past?”
3
TEAM MEDICS: History Taking
CAGE questionnaire: If the patient reports more than 14 standard drinks per week (7-10 drinks per
week for female patients)
Cut down: “Have you ever felt you should CUT DOWN on your alcohol consumption?”
Annoyed: “Have you ever felt ANNOYED when someone criticizes your drinking habit?”
Guilty: “Have you ever felt GUILTY about your drinking habit?”
Eye opener: “Have you ever had a drink first thing in the morning?” (EYE OPENER)
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TEAM MEDICS: History Taking
2-4. Transitions
• Simple Transitions
“Mr Smith, I will now be asking you some questions about allergies.”
• Full Transitions*
Full transitions are necessary when asking about potentially sensitive information:
• ObGyn
• Sexual History
• Social History
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TEAM MEDICS: History Taking
基本情報
患者氏名(アルファベット)
姓(日本語読)
名(日本語読)
ミドルネーム(日本語読)
国籍
滞在先
国内連絡先
母国連絡先
主訴
現病歴
発症
症状の性質
部位 & 放散の有無
程度
関連症状
時間 & 頻度
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TEAM MEDICS: History Taking
同じ症状の既往
アレルギーの既往
入院歴
既往歴
外傷の既往
手術歴
家族歴
産婦人科関連の既往歴(妊娠/出産/中絶/
最終月経日など)
性歴
喫煙
職業
飲酒
ドラッグの使用
その他