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INTRODUCTION

The adult comprehensive history is essentially “the rest of the story.” Once you have asked questions concerning the history of the present illness or condition for which the patient is being seen, use this section to fill in the blanks. The adult comprehensive history is an important piece of the clinical picture taken during the workup of a new patient, and often will help in determining whether the current “chief complaint” is new or if the patient has had similar medical conditions or risks for such in the past.

For billing purposes, the comprehensive adult history is termed the PFSH (Past Family Social History) and contains the following elements:

  • Past medical history includes illnesses, immunizations, operations, injuries, medications, compliance, and treatments.

  • Family history is important to determine genetic disorders, as well as those diseases which may place the patient at risk. For example, the age at which a patient needs colon cancer screening depends on family history. Also, knowing that a patient has a family history of early heart disease is essential in determining cholesterol goals.

  • Social history includes employment and work exposures, education, marital status, substance use, travel and sexual history. Included in this chapter are screening tools for alcohol abuse, domestic violence, and depression. For pediatric social history, see Chapter 10, “Questions for Special Populations.”

The comprehensive adult history included here follows the standard format and order taught in most medical history textbooks.

CHILDHOOD ILLNESSES

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Have you ever had …

¿Ha usted tenido alguna vez …

  • measles?

  • sarampión?

  • mumps?

  • paperas?

  • whooping cough?

  • tos ferina?

  • chicken pox?

  • varicela?

  • smallpox?

  • viruela?

  • scarlet fever?

  • escarlatina?

  • rheumatic fever?

  • fiebre reumática?

  • diphtheria?

  • difteria?

  • polio?

  • polio?

PAST MEDICAL HISTORY

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Do you have …?

¿Usted tiene …?

Have you ever had …?

¿Ha usted tenido …?

Have you been told by a doctor

¿Le ha dicho algún doctor que

  • you have …

  • usted tiene …

  • arthritis?

  • artritis?

  • asthma?

  • asma?

  • bladder infections?

  • infecciones de la vejiga?

  • blood disease (hemophilia, leukemia, anemia)?

  • enfermedades de la sangre (hemofilia, leucemia, o anemia)?

  • bronchitis?

  • bronquitis?

  • cancer?

  • cáncer?

  • diabetes?

  • diabetes?

  • emphysema?

  • enfisema?

  • epilepsy?

  • epilepsia?

  • flu?

  • gripe?

  • gout?

  • gota?

  • hepatitis?

  • hepatitis?

  • heart disease (heart attack)?

  • enfermedades del corazón (ataque al corazón)?

  • enfermedades del corazón (ataque cardiaco)?

  • high blood pressure?

  • alta presión?

  • kidney disease?

  • enfermedades renales?

  • enfermedades de los riñones?

    • infections?

    • infecciones?

    • stones?

    • piedras?

    • dialysis?

    • dialisis?

  • liver disease?

  • enfermedades del hígado?

  • pneumonia?

  • pulmonía?

  • rheumatic fever?

  • fiebre reumática?

  • seizures?

  • convulsiones?

  • thyroid disease?

  • enfermedades de las tiroides?

  • TB?

  • tuberculosis?

  • stomach ulcers?

  • úlceras estomacales?

  • stroke?

  • accidente cerebrovascular (ACV)?

  • derrame cerebral?

  • apoplejía?

  • infarct?

  • infarto?

What year?

¿En que año?

IMMUNIZATIONS

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Have you been vaccinated ...

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