Comprehensive Medical History Gathering

Patient Information and Medical History

The American College of Physicians recommends documenting patient demographics, including name, date of birth, gender, ethnicity/race, to establish patient identity 2
The Centers for Disease Control and Prevention suggests that a comprehensive medical history should include a patient's primary language, years of education, occupation, and living situation to understand patient context and communication needs 2
The Infectious Diseases Society of America recommends documenting the onset and chronology of symptoms, location, quality, severity, duration, context, and modifying factors for every presenting complaint 3
The American Academy of HIV Medicine suggests that for HIV patients, the medical history should include disease-specific details such as date of diagnosis, approximate date of infection, CD4 counts, and viral loads 1, 4

The National Institutes of Health recommends documenting all prescription drugs, including names, dosages, frequencies, and duration of use, as well as over-the-counter medications, supplements, and herbal remedies 1, 2, 3
The American Medical Association suggests that prior medication use, including specific drugs, duration of therapy, complications, side effects, and drug resistance, should be documented 1, 4

The U.S. Preventive Services Task Force recommends documenting a three-generation family history, focusing on first-degree relatives with relevant conditions, as well as early coronary heart disease and hereditary conditions 1, 2, 4
The Centers for Disease Control and Prevention suggests that social history should include substance use, such as tobacco, alcohol, and recreational drugs, as well as occupational and environmental exposures 3, 4

The American College of Physicians recommends a comprehensive symptom review with an HIV-specific emphasis, including constitutional, HEENT, cardiovascular, respiratory, gastrointestinal, genitourinary, musculoskeletal, dermatologic, and neurologic symptoms 1, 5
The Infectious Diseases Society of America suggests that the physical examination should include vital signs, measurements, and a targeted examination based on the presenting complaint, including general appearance, mental status, body habitus, and lymph nodes 2, 5

The National Institutes of Health recommends documenting pertinent negatives to demonstrate thoroughness, using clear language, and documenting the source of information 3, 4
The American Medical Association suggests that patient literacy and primary language should be assessed and documented 4