Format for history taking:
GCSE
Greeting
Confidentially
Concern
Sympathy
Empathy
ODPARA
Onset
Duration
Progression
Aggravating Factor
Relieving Factor
Associated symptoms
Anything Else
Non-pain related complaint: ODPARA
Onset
“How did it start?
What were you doing when it started?
Did any happed prior to …”
Duration
Most of the time it is written in the task, just check it with the patient.
Progression
“Has it been getting worse or has it been getting better?”
Aggravating Factor
“Have you noticed what makes it worse?”
Relieving Factor
“Have you tried to make it better?”
Associated symptoms
“Do you have temperature?” (Fever is a clue in GMC exam)
“Do you have pain?” If patient says yes go for SOCRATES PDA
“Did it start together?”
Vomiting?
SOCRATES PDA
Site
Onset
Character
Radiation
Associated symptoms
Timing
Exacerbating and Relieving Factor
Scale
Progression
Duration
Anything Else
SOCRATES PDA pain related
Site: “where is in the tummy do you feel the pain most?”
Onset: “How did the pain start? “
Character: “could you please describe the pain for me?”
Radiation:”Does this pain go anywhere else?” No ask: “Has it come from anywhere else?”
Yes: ask where?
Associated symptom: stick on your diagnosis.
Trimming: “Does it from specific timing? “
“Has it happened before? Is the pain constant, or does it come and go?”
Exacerbating and relieving factors: “Does anything make it better? Is the pain relieved on defecation?”
Scale: “if I was to give to give you the scale1-10, one is lowest and 10 is highest, what do you describe the pain?” If answer is Under 7 ignore it… 8-10 severe like MI
Progression: “Is it increased or getting worse?”
Duration: always written in your task.
Anything else:
3 Ps: Present complaint, Past complains, Personal history
I. Present complains: "Do you mind if I ask you what has brought you into hospital (here)?"
Tip: First thing comes of patient month is chief complaint.
II. Past complains:
Similar complains: “has anything like this has been happened to you? For how long? What did you take for it? Is it well controlled?”
Medication: “Do you have any long time medical condition?” Yes how long? Is it well controlled?”
Hospitalisation: have you ever been hospitalized? Yes. What for? Procedure Endoscopy…..
III. Personal complains:
“I’m going to ask you few personal Questions; and whatever you say will be confidential.”
Smoking (4Qs)
1. Do you smoke? Yes…
2. How many cigarettes do u smoke a day?
3. How many cigarettes are there in a pack?
4. For how long have u been smoking?
sleep
Alcohol (4Qs)
1. Do you drink alcohol? If he says occasionally leave it. If says yes,
2. Ask what do u prefer to drink?
3. How much?
4. For how long have u been drinking like this? Appetite
Recreational drugs
1. “By any change do you take recreation drugs?” Yes.
2. Sorry to ask you but what do you do?
3. How do you take it?
4. If injecting, ask: By any chance do you use new needle all the time?
5. For how long are you doing this?
6. Do you use any other recreational drugs? Weight loss/ gain
Have you been weighting on the higher site? (for
obesity)
Bowel habits
1. How often do you open your bowels?
2. Have you noticed any change?
3. Any alteration in bowel habit? Bladder
Sexual history:
1-Are you sexually active? No… Have you ever been sexually active? Yes…
2- Sorry to ask you this but Are you in a stable relationship? For how long? Do you practice safe sex? Do you use condoms? Are you on any contraception? What is your sexual orientation? Which root do you take? Did you travel abroad before your symptoms? Did you have any sex relationship there?
3- I am sorry to ask you but by any chance, your partner has any sexual relationship?”
If patient is a woman, ask 4Ps
Period (LMP) 1-“When was your last periods?”
If > 4 weeks then she might be pregnant.
If she is not sexually active then she is not pregnant.
2- How many days do they last?
3- Are they regular?
4- Do you get pain? ( ovulation)
4- Any bleeding between your periods or after intercourse?
(ovulation, hormonal imbalance, cervical polyp, PID, cervical erosion)
Pills
GCSE
Greeting
Confidentially
Concern
Sympathy
Empathy
ODPARA
Onset
Duration
Progression
Aggravating Factor
Relieving Factor
Associated symptoms
Anything Else
Non-pain related complaint: ODPARA
Onset
“How did it start?
What were you doing when it started?
Did any happed prior to …”
Duration
Most of the time it is written in the task, just check it with the patient.
Progression
“Has it been getting worse or has it been getting better?”
Aggravating Factor
“Have you noticed what makes it worse?”
Relieving Factor
“Have you tried to make it better?”
Associated symptoms
“Do you have temperature?” (Fever is a clue in GMC exam)
“Do you have pain?” If patient says yes go for SOCRATES PDA
“Did it start together?”
Vomiting?
SOCRATES PDA
Site
Onset
Character
Radiation
Associated symptoms
Timing
Exacerbating and Relieving Factor
Scale
Progression
Duration
Anything Else
SOCRATES PDA pain related
Site: “where is in the tummy do you feel the pain most?”
Onset: “How did the pain start? “
Character: “could you please describe the pain for me?”
Radiation:”Does this pain go anywhere else?” No ask: “Has it come from anywhere else?”
Yes: ask where?
Associated symptom: stick on your diagnosis.
Trimming: “Does it from specific timing? “
“Has it happened before? Is the pain constant, or does it come and go?”
Exacerbating and relieving factors: “Does anything make it better? Is the pain relieved on defecation?”
Scale: “if I was to give to give you the scale1-10, one is lowest and 10 is highest, what do you describe the pain?” If answer is Under 7 ignore it… 8-10 severe like MI
Progression: “Is it increased or getting worse?”
Duration: always written in your task.
Anything else:
3 Ps: Present complaint, Past complains, Personal history
I. Present complains: "Do you mind if I ask you what has brought you into hospital (here)?"
Tip: First thing comes of patient month is chief complaint.
II. Past complains:
Similar complains: “has anything like this has been happened to you? For how long? What did you take for it? Is it well controlled?”
Medication: “Do you have any long time medical condition?” Yes how long? Is it well controlled?”
Hospitalisation: have you ever been hospitalized? Yes. What for? Procedure Endoscopy…..
III. Personal complains:
“I’m going to ask you few personal Questions; and whatever you say will be confidential.”
Smoking (4Qs)
1. Do you smoke? Yes…
2. How many cigarettes do u smoke a day?
3. How many cigarettes are there in a pack?
4. For how long have u been smoking?
sleep
Alcohol (4Qs)
1. Do you drink alcohol? If he says occasionally leave it. If says yes,
2. Ask what do u prefer to drink?
3. How much?
4. For how long have u been drinking like this? Appetite
Recreational drugs
1. “By any change do you take recreation drugs?” Yes.
2. Sorry to ask you but what do you do?
3. How do you take it?
4. If injecting, ask: By any chance do you use new needle all the time?
5. For how long are you doing this?
6. Do you use any other recreational drugs? Weight loss/ gain
Have you been weighting on the higher site? (for
obesity)
Bowel habits
1. How often do you open your bowels?
2. Have you noticed any change?
3. Any alteration in bowel habit? Bladder
Sexual history:
1-Are you sexually active? No… Have you ever been sexually active? Yes…
2- Sorry to ask you this but Are you in a stable relationship? For how long? Do you practice safe sex? Do you use condoms? Are you on any contraception? What is your sexual orientation? Which root do you take? Did you travel abroad before your symptoms? Did you have any sex relationship there?
3- I am sorry to ask you but by any chance, your partner has any sexual relationship?”
If patient is a woman, ask 4Ps
Period (LMP) 1-“When was your last periods?”
If > 4 weeks then she might be pregnant.
If she is not sexually active then she is not pregnant.
2- How many days do they last?
3- Are they regular?
4- Do you get pain? ( ovulation)
4- Any bleeding between your periods or after intercourse?
(ovulation, hormonal imbalance, cervical polyp, PID, cervical erosion)
Pills