How to Take a Medical History

Two Parts:Gathering Information Before Your AppointmentProviding Information at the Appointment

Having a doctor take your medical history is an extremely important part of being treated. It gives the doctor an overview of your current health, past health conditions you have had, and what conditions may run in your family. Provide your doctor with as much information as you can to help get accurate, efficient treatment.

Part 1
Gathering Information Before Your Appointment

  1. Image titled Take a Medical History Step 1
    Collect information on your family. Information on your family members’ health is important for identifying conditions that may run in your family. If your family members have a condition that has a genetic component, you might, in some cases, also be vulnerable. Your medical history should go back at least three generations. This means you should include your:[1][2]
    • Parents
    • Grandparents
    • Children
    • Grandchildren
    • Siblings
    • Aunts and uncles
    • Cousins
  2. Image titled Take a Medical History Step 2
    Include as much medical information as possible. The more information you can provide, the easier it will be for the doctor to reconstruct what conditions your family members may have had. Try to include as much of the following as you can for each person:[3][4]
    • Date of birth
    • Sex
    • Ethnicity — this can be helpful because some ethnic groups have higher risks for particular conditions
    • Age at death
    • Cause of death
    • Medical conditions — this includes physical and mental health conditions and intellectual disabilities
    • Age when the condition was diagnosed
    • Pregnancy complications such as miscarriages, birth defects, fertility problems
    • Details about the person’s lifestyle, such as drinking or smoking
    • If there is any possibility that your parents are related to each other through blood.
    • If the person was with physical malformations at birth that was, repaired such as cleft lip
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    Search persistently. You may be able to get some information easily through what you know about your family or simply by asking. However, for relatives that are deceased or with whom you may not have contact, this can be more difficult. Depending upon your situation, sources of information may include:[5][6]
    • Family records including family trees, genealogies, baby books, letters, or electronic health records.
    • Public records such as birth certificates, marriage licenses, death certificates, obituaries, records from religious institutions. Newspapers and government offices often contain birth, death and marriage announcements.
    • Your adoption agency. If you were adopted, the agency that managed your adoption may have either provided medical information to your adoptive parents or may keep it on file. You can also contact the National Adoption Clearinghouse or go to
    • Your sperm/egg bank. If you were conceived with donated sperm or eggs, the bank likely has medical records that they collected while screening the donors. This information is often provided to the parents and children. You can also search for donor sibling registries online to determine whether you may have half siblings via the same donor who might have developed health conditions.[7]

Part 2
Providing Information at the Appointment

  1. Image titled Take a Medical History Step 4
    Describe any past or present conditions that you have. This may includes both physical and mental health and acute and chronic conditions. You should tell the doctor:[8]
    • When the condition developed
    • How long you had it
    • What symptoms you had
    • How it was treated
  2. Image titled Take a Medical History Step 5
    Tell the doctor about any past surgeries or hospitalizations. The doctor will likely want to know:[9]
    • What the problem was
    • How it was treated
    • Where you were treated — the doctor may ask for medical records from the procedures or treatments
    • If there were any complications during the treatment
    • If you had any adverse reactions to anesthesia
  3. Image titled Take a Medical History Step 6
    Give the doctor a list of all medications that you take. This should include both drugs you are currently taking and those you have previously taken. It includes prescription drugs, over-the-counter medications, alternative medicines, herbal remedies, dietary supplements and vitamins. It is important for the doctor to know about everything because some substances, even herbal remedies or vitamins, can interact with medications. If you are unsure how to describe it to your doctor, you can bring the pill bottles to your appointment and the doctor will be able to obtain the necessary information from the prescriptions. For everything you take, the doctor will want to know:[10]
    • The dosage
    • The frequency with which you take it
    • What you take it for
    • How long you have been taking it
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    Describe your allergies. Many people see the doctor for relief from seasonal allergies, but there are also many other things that trigger allergic reactions. For each type of allergy you have, describe what the trigger is and how you react to it. Common triggers for allergic reactions include:[11]
    • Seasonal sources like plant pollen
    • Dust
    • Pet dander
    • Anesthesia
    • Latex
    • Foods, for example nuts
    • Bee stings
    • Medications, including some antibiotics
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    Provide your doctor with your vaccine history. This is important for determining whether you may need boosters for some vaccines. Tell your doctor when you last received which vaccines and whether you have recently or will soon travel to a place where you may need additional vaccines. Vaccines are available for:[12][13]
    • Flu (nasal spray or shot)
    • Pneumonia
    • Polio
    • Tetanus
    • Chicken pox
    • Diphtheria
    • Hepatitis A
    • Hepatitis B
    • Measles
    • Mumps
    • Rubella
    • HiB
    • Pertussis
    • Rotavirus
    • Yellow fever
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    Answer honestly when your doctor asks about your lifestyle. Your doctor will likely be interested in the health risks you encounter in your environment and helping you to minimize them. Your doctor may ask about:[14]
    • Your job. Some jobs have health risks including exposure to dangerous chemicals or radioactive substances. Your doctor may be able to advise you on how to reduce your exposure through using protective gear.
    • Substance use. This may include the use of alcohol, tobacco, or recreational drugs. If you are interested in quitting drinking, smoking, or taking drugs, your doctor will be able to advise you on what resources are available to help you.
    • Sexual activity. You may feel that the doctor is asking very invasive questions, but it is important you answer as honestly as possible. She may ask about how many partners in the past year, the sex of your partners, if you practice anal intercourse, if you use contraception, if there have been any pregnancies, and so on. Your doctor will be able to provide you with information about the risks and possible solutions, including different forms of birth control.
    • Your dietary and exercise habits. Eating healthy and exercising reduces your risk for many conditions, especially cardiovascular conditions. This means that your doctor will probably want to know if your diet and exercise habits are likely to be improving or harming your long-term health.
  7. Image titled Take a Medical History Step 10
    Ask your doctor if you need regular screenings. Your doctor may suggest regular screenings if you are at a high risk for developing a particular condition. If this is the case, the doctor will tell you how frequently to come into be checked. You many need screenings based on the following:
    • A family history of a condition like cancer which may have a genetic component
    • A prior diagnosis of a serious condition that is now in remission
    • Warning signs that you may be at the early stages of developing a health problem
    • Your age and gender, such as colonoscopies beginning at age 50, etc.

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