CHECKLIST FOR HISTORY TAKING YOU ARE THE DOCTOR TALKING TO THE PATIENT No STEPS & CRITERIA DONE Say hello Introduce yourself - name & role My name is and I will be your doctor today/I am in charge of the clinic today (+) Hand sanitizer Confirm patient details - name & DoB Explain the need to take history (as a doctor) I need to ask you some questions before examining you This will give me more information so that I can make a correct diagnosis Gain consent Ask about chief complaint (CC) Ask for details of CC: duration location severity relieving or aggravating factors medication Ask about other symptoms Ask about previous health: past medical history family history 10 Talk to the patient about next step 11 Summarize the case A year-old male/female patient complaint of (details of CC) (Other symptoms & previous health) In conclusion, I think the patient is having an issue with his/her system (+) Make a possible diagnosis 12 Communication skills (on a scale from 1-5; the higher, the better) * Pronunciation * Fluency * Active listening to the patient * Terminology in summary COMMENT: _ _ _ _ TOTAL: NOTE