Clinical exam · History taking and the interview
Past medical, surgical, family and social history !
- History
The past history gathers the patient's illnesses, operations and habits and the family's diseases that may explain the current problem.
Updated 2026-11-01
What it is
The past history records what happened before the current problem: the patient's illnesses, operations, hospital stays, injuries, transfusions and vaccines, the family's diseases and the patient's living conditions. Many diagnoses become clear here: a febrile patient who travelled to an endemic area, or colon cancer in a young sibling. In Colombia it is usually ordered by type: medical, surgical, medicines, allergies, substance use, trauma, transfusions, gynaecologic-obstetric and family.
What it must include
- For each illness: year of diagnosis, treatment and current control.
- For each operation: type, date, reason and complications (including anaesthetic ones).
- A family tree (genogram) of at least three generations when a hereditary disease is suspected; it is updated over the years.
- Cause and age of death of deceased relatives.
- Occupation, housing and services, schooling, physical activity, diet, sexual history, place of origin and travel.
How to ask
- 'What illnesses have you been diagnosed with? Since when, and how are they controlled?'
- 'Have you had any operations? What, when, and were there complications?'
- 'Have you been in hospital, or had accidents or fractures?'
- 'Have you ever had a blood transfusion?'
- 'Do your father, mother, brothers, sisters or children have or have had any illness? At what age?'
- 'What is or was your work? Are you exposed to chemicals, dust or noise?'
- 'Where were you born and where do you live? Who do you live with? Have you travelled recently?'
Test yourself
Think of the answer, then tap the question to see it.
Which types of personal history are usually recorded in the Colombian clinical history?
Medical, surgical, medicines, allergies, substance use, trauma, transfusions, gynaecologic-obstetric and immunisations.
Which family history defines premature cardiovascular disease?
A cardiovascular event in a first-degree relative: a man before age 55 or a woman before age 65.
Why does it matter where a patient in Colombia was born and has lived?
Because origin in rural or endemic areas points to diseases such as Chagas, malaria, leishmaniasis or tuberculosis.
What does breast and ovarian cancer in several women of the same family suggest?
A hereditary breast and ovarian cancer syndrome, such as the one linked to BRCA1 or BRCA2 mutations.
Related
- The clinical history: its parts and their order
- Medicines, allergies and habits: tobacco, alcohol and other substances
- Gynecologic and obstetric history
- Review of systems
Related conditions
- Hereditary breast and ovarian cancer syndrome (BRCA1/BRCA2)
- Lynch syndrome (hereditary non-polyposis colorectal cancer)
- Chagas disease
- Type 2 diabetes mellitus
- Arterial hypertension
Educational content on the clinical exam; it is learned and practised under supervision. It does not replace assessment by a health professional and is not for self-diagnosis.
Sources: 12.3 Collection of Assessment Data - Fundamentals of Nursing | OpenStax (OpenStax, Rice University, 2024); Talking With Your Doctor: MedlinePlus (U.S. National Library of Medicine, 2025); The Family History - Clinical Methods - NCBI Bookshelf (Butterworths (NCBI Bookshelf), 1990).
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Representative model, for educational purposes only.