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Taking a medical history is one of the most important parts of patient care because it provides a systematic account of the patient’s health, present illness, past illnesses, family background, lifestyle, and other factors that may influence health. A well-recorded medical history helps a healthcare professional understand the patient’s condition, identify possible causes of illness, decide which examinations are necessary, and plan appropriate treatment. Medical history should therefore be written in a clear, organized, accurate, and chronological manner. Good communication with the patient is essential because the quality of the history depends largely on how comfortably and openly the patient can describe the problem. The medical history normally begins with the patient’s identification details. These include the patient’s name, age, sex, occupation, address, date of consultation or admission, and other relevant identifying information. In a hospital record, registration or identification numbers may also be included. These details are important because certain diseases are related to age, sex, occupation, or living conditions. For example, occupational exposure may increase the risk of particular respiratory or chemical-related illnesses. The next part is the chief complaint. The chief complaint states the main reason why the patient has come for medical attention. It should be recorded briefly and, as far as possible, in the patient’s own ______ _______ ______ _____ ___ ___ ________ __________.
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