Past medical history drugs and allergies

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Medical history

Medical history

Illness

Operations

Anaesthetics

Treatments

Vaccinations Medicals Screening tests

Myocardial infarction

Stroke

Diabetes

Asthma

Jaundice

Tuberculosis

Rheumatic fever

Epilepsy

Alcohol, smoking

Drugs

What?

Prescribed

Alternative

Illicit

Compliance

Intolerances

Allergies (record clearly in notes)

Dose

Frequency Route

Drugs

Food

Venom

Oedema

Medicalert / /

Rash

Shock

Other

Oedema

Medicalert / /

The PMH is a vital part of the history. It is important to record in detail all previous medical problems and their treatment. It is also useful to record this information in chronological order. You could ask: 'What illnesses have you had'?, 'What operations'?, 'Have you ever been in hospital'?, 'When did you last feel completely well'? Ask if there were any problems with operations or anaesthetics, and, if so, what they were. You might turn up a bleeding tendency or an intolerance to particular anaesthetic agents.

If not already discussed in relation to the presenting complaint, specific PMH may need to be enquired about. For example, ask about previous chest pain (angina) in a patient presenting with severe chest pain.

It is conventional to record the occurrence of specific common illnesses, in particular jaundice, anaemia, TB, rheumatic fever, diabetes mellitus, bronchitis, MI, stroke, epilepsy, asthma and problems with anaesthesia.

The patient should also be asked about vaccinations, medicals, screening tests (e.g. cervical smear) and pregnancies.

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