When taking a patient's history, a structured approach helps ensure you don't miss important information.

1. Chief Complaint (CC)

• "What brings you in today?"

• "What is your main concern?"

2. History of Present Illness (HPI)

Use OLD CARTS or OPQRST:

Onset

• When did it start?

• Was it sudden or gradual?

Location

• Where is the problem located?

Duration

• How long has it been going on?

• Is it constant or intermittent?

Character

• Can you describe the symptom?

• Is the pain sharp, dull, burning, stabbing, cramping?

Aggravating/Relieving Factors

• What makes it worse?

• What makes it better?

Radiation

• Does the pain move anywhere else?

Timing

• Is it worse at a particular time of day?

Severity

• On a scale of 0–10, how severe is it?

Associated Symptoms

• Have you noticed any other symptoms?

• Fever, nausea, vomiting, weight loss, cough, shortness of breath, etc.

3. Past Medical History (PMH)

• Do you have any medical conditions?

• Have you ever been hospitalized?

• Have you had similar symptoms before?

4. Past Surgical History (PSH)

• Have you had any surgeries or procedures?

5. Medications

• What medications do you take?

• Any over-the-counter medications or supplements?

6. Allergies

• Do you have any allergies?

• What reaction do you get?

7. Family History

• Any family history of heart disease, diabetes, cancer, hypertension, or genetic disorders?

8. Social History

• Do you smoke?

• Do you drink alcohol?

• Do you use recreational drugs?

• What do you do for work?

• Who do you live with?

• Are you sexually active?

9. Review of Systems (ROS)

Screen for symptoms in major systems:

General

• Fever, chills, fatigue, weight changes?

Cardiovascular

• Chest pain, palpitations, leg swelling?

Respiratory

• Cough, shortness of breath, wheezing?

Gastrointestinal

• Abdominal pain, nausea, vomiting, diarrhea, constipation?

Genitourinary

• Dysuria, frequency, hematuria?

Neurologic

• Headache, weakness, numbness, dizziness?

Example Opening

"Hello, I'm Dr. Ahmad. What brings you in today?"
"Can you tell me more about your symptoms?"
"When did they start?"
"Have you experienced anything like this before?"

For USMLE, shelf exams, and clinical rotations, remember the standard order:

(1) CC → (2) HPI (OLD CARTS) → (3) PMH → (4) PSH → (5) Medications → (6) Allergies → (7) Family History → (8) Social History → (9) ROS.