What is a medical history?
The definition of a medical history is “previous history of an illness”. With the help of open and specific questions, the doctor or healthcare professional obtains information not only about a patient’s current complaints, but also about their medical history and life circumstances. The initial anamnesis is particularly detailed so that the doctor can get a comprehensive picture of the patient.
If the anamnesis interview takes place with the patient themselves, this is referred to as a personal anamnesis. If other people, such as close relatives, are interviewed, this is known as an external medical history. In addition, medical histories can be divided into different subgroups if they are based on a specific subject or topic.
|
medical history |
Contents |
Purpose |
|
Care history |
||
|
Family history |
||
|
Social history |
||
|
Vegetative anamnesis |
||
|
Pain history |
||
|
Biographical anamnesis (psychosomatics and psychiatry) |
||
|
Nutritional history |
||
|
Medication history |
When do you take a medical history?
What do you do during an anamnesis?
To begin with, the doctor will ask you why you are consulting him. He will also ask more detailed questions about your current complaints so that he can get a better picture. Typical anamnesis questions may include:
- What brings you to me?
- Where and since when have you had the complaints?
- Have the symptoms changed over time?
- Has anything already been done?
In order for your doctor to get to know you and your medical history better, he or she will also discuss any previous illnesses, operations you have already had, risk factors and allergies, for example:
- Have you ever been hospitalized?
- Do you suffer from high blood pressure?
- Do you have allergies?
The current state of health also provides important information in terms of the vegetative anamnesis:
- Has your appetite or thirst changed?
- Do you often sweat at night?
- Have your bowel movements or sleeping habits changed?
- For women: When was your last period?
A detailed medical history interview also includes a medication, family and social history. Possible questions include:
- Are you taking medication?
- Did your parents have any health problems?
- Who looks after you when you are unwell?
Although a medical history interview can have a certain structure and a clear procedure, it will be adapted to your symptoms and expanded if necessary. This is followed by a physical examination and further diagnostic steps such as an X-ray or a blood test.
If you wish, you can bring a relative or close friend with you to the (initial) medical history.
What are the risks of a medical history?
As a rule, taking a medical history as such does not involve any risks and also serves to establish a trusting relationship between doctor and patient. The information you provide to the doctor or healthcare professional is subject to confidentiality.
In rare cases, misunderstandings can arise, which you can prevent by providing precise information or the doctor by asking precise questions.
What do I need to bear in mind when taking a medical history?
The medical history is used to make a diagnosis and should therefore be as detailed as possible. Tell your doctor about things that may not initially seem important to you in relation to your complaints or illness. There is nothing to be ashamed of and you can communicate openly with your doctor.
If anything is unclear to you during the medical history or you feel uncomfortable, say so immediately. In the event of a language barrier, an interpreter can translate the medical history interview at any time.
