Doctoring: Master History Checklist

Vocabulary flashcards covering key terms and definitions from the Doctoring Master History Checklist, including patient interview structure, symptom analysis, social and sexual history components, review of systems, and professional behaviors.

“Foam in”

Use an alcohol-based cleanser or wash hands before touching or examining a patient.

“Foam out”

Use an alcohol-based cleanser or wash hands after completing the patient encounter.

Introduce yourself

State your name and role to the patient at the start of the visit.

Preferred form of address

Ask how the patient wishes to be called and confirm pronouns to ensure respectful communication.

Inclusive language

Use gender-neutral, non-stigmatizing words throughout the interview.

Agenda setting

Negotiate what will be covered (history, exam, patient concerns) at the start of the encounter.

Primary Care Physician (PCP)

Identify whether the patient has a regular doctor and document the name.

Chief Complaint (CC)

The patient’s main reason for seeking care, recorded in the patient’s own words.

History of Present Illness (HPI)

Chronologic, detailed exploration of the chief complaint using symptom analysis questions.

Onset (HPI element)

When the symptom first began.

Provocation / Aggravating factors

Actions or circumstances that make a symptom worse.

Palliation / Alleviating factors

Actions or circumstances that make a symptom better.

Quality of symptom

Description of what the symptom feels like (e.g., stabbing, throbbing, productive cough).

Region / Location

The exact area on the body where the symptom occurs.

Radiation

Movement of a symptom or pain to other body areas.

Severity

Intensity of the symptom, often rated 0–10 for pain.

Associated symptoms

Other complaints that accompany the chief concern.

Temporal profile / Frequency

How long, how often, and the course of the symptom over time.

Previous similar episodes

Past occurrences of the same problem and how they were treated.

Patient concerns & expectations

Ask what the patient fears or anticipates about the illness and its treatment.

Open-to-closed questioning

Start with open questions, then narrow to specifics for detail.

Segment summary

Brief recap of information gathered, allowing the patient to correct or add details.

Transition statement

A verbal cue that signals moving to a new part of the interview (e.g., "Now I’d like to ask about your past health").

Past Medical History (PMH)

List of active problems, childhood illnesses, hospitalizations, surgeries, and medications.

Childhood illnesses & immunizations

Record significant early diseases and vaccination status.

Hospitalizations

Year and reason for any inpatient stays.

Previous surgeries

Year, type of operation, and complications, if any.

Prescription medications

Current drugs with dose and frequency.

Over-the-counter medications

Non-prescription drugs and supplements the patient takes.

Herbal or alternative treatments

Complementary therapies or remedies in use.

Drug allergies

Medications that cause adverse reactions for the patient.

Allergic reaction description

Specific symptoms experienced during an allergy (e.g., rash, anaphylaxis).

Family History (FH)

Illnesses among parents, siblings, children, and other relatives, including ages and causes of death.

Social History (SH)

Living situation, relationships, occupation, stressors, lifestyle habits, and safety concerns.

Living arrangements

Where and with whom the patient lives.

Sources of social support

Family, friends, or community that assist the patient.

Occupation & hazards

Work status and exposures that may affect health.

Stressors & financial hardship

Social or economic problems impacting health or treatment.

PHQ-2 depression screen

Two questions on interest/pleasure and feeling down; each scored 0–3.

PHQ-2 positive cutoff

A combined score of 3 or more suggests risk for depression.

Safety / interpersonal violence screen

Questions about being hit, feeling safe in current or past relationships.

Tobacco use assessment

Type, amount per day, duration, time to first cigarette, and quit attempts.

Alcohol use low-risk limits (women)

3 drinks/day or >7 drinks/week triggers further screening.

Alcohol use low-risk limits (men)

4 drinks/day or >14 drinks/week triggers further screening.

Binge drinking screen

≥5 drinks (men) or ≥4 drinks (women) in one day, more than once in past year is positive.

CAGE-AID questionnaire

Cut down, Annoyed, Guilty, Eye-opener questions for alcohol and drug use.

Recreational drug use screen

Ask about nonmedical use of drugs in the past year and details of use.

Sexual history transition

Obtain permission to discuss sexual health before asking sensitive questions.

5 P’s of sexual history

Partners, Practices, Protection from STIs, Past STIs, Prevention of pregnancy.

Partners (sexual history)

Number, gender, and concurrency of sexual partners.

Practices (sexual history)

Types of sexual contact (oral, genital, anal, etc.).

Protection from STIs

Methods used and frequency of barrier protection.

Past history of STIs

Previous infections, treatment, and follow-up testing.

Prevention of pregnancy

Desire for pregnancy and current contraception method.

Review of Systems (ROS)

Systematic yes/no checklist of symptoms across body systems.

General / Constitutional ROS

Fever, chills, weight change, fatigue, night sweats.

HEENT ROS

Headache, hearing loss, tinnitus, nosebleeds, sore throat, dysphagia.

Eye ROS

Vision changes, double vision, eye pain, redness, discharge.

Cardiovascular ROS

Chest pain, palpitations, dyspnea on exertion, orthopnea, edema.

Respiratory ROS

Dyspnea at rest or activity, cough, sputum color, wheezing.

Gastrointestinal ROS

Nausea, vomiting, heartburn, abdominal pain, bowel changes, jaundice.

Genitourinary ROS

Frequency, urgency, dysuria, hematuria, sexual or menstrual concerns.

Musculoskeletal ROS

Muscle aches, joint pain, stiffness, limited movement.

Integumentary / Breast ROS

Rashes, lesions, mole changes, breast pain or lumps.

Neurologic ROS

Headache, numbness, dizziness, seizures, balance problems.

Psychiatric ROS

Depression, anxiety, insomnia, suicidal or homicidal thoughts.

Endocrine ROS

Polyuria, polydipsia, polyphagia, heat or cold intolerance.

Hematologic / Lymphatic ROS

Easy bruising, bleeding, swollen glands, recent travel.

Allergic / Immunologic ROS

Environmental or food allergies, sick contacts.

Empathy

Verbal and non-verbal behaviors that convey care and concern for the patient.

Avoid medical jargon

Use plain language understandable to patients.

Encounter summary

Clinician reviews key points of the visit with the patient before closing.

Addressing questions & concerns

Invite the patient to ask anything unclear or troubling before the visit ends.

Express appreciation

Thank the patient for their time and cooperation.