[Durgical](https://durgical.com/en/) › [DurgiPedia](https://durgical.com/en/durgipedia/) › [Clinical exam](https://durgical.com/en/clinical-exam/) › [History taking and the interview](https://durgical.com/en/clinical-exam/#a-history) › Past medical, surgical, family and social history [Clinical exam](https://durgical.com/en/clinical-exam/) · [History taking and the interview](https://durgical.com/en/clinical-exam/#a-history) # 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 ## Key points - Personal history: medical, surgical, medicines, allergies, substance use, trauma, transfusions, gynaecologic-obstetric and immunisations. - Family history: above all parents, siblings and children (first degree), with the age at which they became ill. - Premature cardiovascular disease in a first-degree relative (a man before 55, a woman before 65) raises risk. - Cancer in several relatives or at a young age suggests hereditary syndromes (breast and ovary, colon). - Social history covers occupation, housing, schooling, support, travel and exposures; in Colombia, rural origin points to Chagas, malaria or leishmaniasis. ## 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?' ## Memory aid The past history looks back in three directions: the patient's own past, the family's, and that of the place where the patient lives. ## 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. [Add to my cards (4)](https://durgical.app/estudiar/?add=/en/clinical-exam/past-medical-surgical-family-and-social-history/) ## Related - [The clinical history: its parts and their order](https://durgical.com/en/clinical-exam/the-clinical-history-its-parts-and-their-order/) - [Medicines, allergies and habits: tobacco, alcohol and other substances](https://durgical.com/en/clinical-exam/medicines-allergies-and-habits-tobacco-alcohol-and-other-substances/) - [Gynecologic and obstetric history](https://durgical.com/en/clinical-exam/gynecologic-and-obstetric-history/) - [Review of systems](https://durgical.com/en/clinical-exam/review-of-systems/) ## Related conditions - [Hereditary breast and ovarian cancer syndrome (BRCA1/BRCA2)](https://durgical.com/en/conditions/hereditary-breast-and-ovarian-cancer-syndrome/) - [Lynch syndrome (hereditary non-polyposis colorectal cancer)](https://durgical.com/en/conditions/lynch-syndrome/) - [Chagas disease](https://durgical.com/en/conditions/chagas-disease/) - [Type 2 diabetes mellitus](https://durgical.com/en/conditions/type-2-diabetes-mellitus/) - [Arterial hypertension](https://durgical.com/en/conditions/arterial-hypertension/) [← All of the clinical exam](https://durgical.com/en/clinical-exam/) 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](https://openstax.org/books/fundamentals-nursing/pages/12-3-collection-of-assessment-data) (OpenStax, Rice University, 2024); [Talking With Your Doctor: MedlinePlus](https://medlineplus.gov/talkingwithyourdoctor.html) (U.S. National Library of Medicine, 2025); [The Family History - Clinical Methods - NCBI Bookshelf](https://www.ncbi.nlm.nih.gov/books/n/cm/A6016/) (Butterworths (NCBI Bookshelf), 1990). ## **Spotted a mistake?** We are always improving for the community. Tell us what is wrong and our team will review it. Report a mistake Representative model, for educational purposes only. --- Source: https://durgical.com/en/clinical-exam/past-medical-surgical-family-and-social-history/ License: CC BY 4.0 (https://creativecommons.org/licenses/by/4.0/). Cite as: DurgiPedia (durgical.com), https://durgical.com/en/clinical-exam/past-medical-surgical-family-and-social-history/