An essential interview process conducted between the patient and health care provider to obtain information about the patient is known as a medical history. The information retrieval process can be a questionnaire, personal interview, or both. The patient's complaints of subjective sensations are known as symptoms. Objective findings detected during an examination are known as signs. During the interview a doctor - patient relationship is established resulting in mutual trust and understanding. The old adage, "listen to the patient they will tell you what is wrong with them" remains true today. An accurate diagnosis is essential for proper treatment. The traditional medical history is outlined as follows:
ID - Identification
CC - Chief Complaint
HPI - History of Present Illness
Onset date
Location of complaint
Duration
Frequency
Character of complaint
Remission
Exacerbation
Prior treatment
PMH - Past Medical History
Allergies
Medications
Operations
Hospitalizations
Past serious illnesses
Prior anesthetic experience
Dental
FH - Family History
SH - Social History
Tobacco
Alcohol
Education
Occupation
Religious background
ROS - Review of Systems (head, eyes, ears, nose, dental, mouth, throat, face,
cardiorespiratory, gastrointestinal, musculoskeletal, genitourinary, nervous, and integument)