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Taking a Medical History

When taking a medical history from a client it is very important to phrase your questions correctly. Asking, "Does Fred drink a lot of water?" is leading the client, and possibly in the wrong direction. Just as when you are performing a physical examination, your job is to collect as much information as possible and asking questions in the same order every time will lead to a complete history.

You should always review the patient's chart prior to meeting with the client. If possible it is a good idea to read through at least the last year of visits. That can seem like a lot of information but there are many times when a DVM suggested a diagnostic test that has somehow been missed or a phone message the client never received. Our job is not to let anything slip by.

Review the patient's problem list, vaccine history and last blood work performed and look at the blood results. By reviewing these you will know what to discuss with the owner.

Review the signalment; age, species/breed, gender/altered.

Know not just the patient's and client's names but how to pronounce them prior to entering the exam room.

When entering the exam room be sure to introduce yourself to the client and the patient. If you already know the client, a sincere greeting and a few cordial words prior to taking the history will most likely put the client at ease which will make your job easier.

The following questions may seem unnecessary to the client, especially if the pet is ill, but take a few moments to explain the importance to the client. You need to consider the reason the pet is being seen and collect all the information needed to immediately treat the patient, but at some point you will need to have all the questions answered. The questions that follow should be asked at any visit, well or sick; additional questions below are indicated only for sick visits. Keep in mind it is not possible for us to touch on every illness or injury a patient will present for in this article.

It is a good idea when taking a history to use a checklist; this is a great way of making sure we do not forget anything.

For all patients

  1. Chief complaint or reason for visit?
  2. Any vomiting? If yes continue to questions a-h
    1. When did it start?
    2. How soon before or after eating does the vomiting occur?
    3. Is the food digested?
    4. Are there any foreign items in the vomit?
    5. What is the consistency of the vomit?
    6. How frequently are they vomiting?
    7. Could they have eaten something inappropriate?
    8. Have you recently changed their diet?
  3. Any diarrhea? If yes continue to questions a-g
    1. When did it start?
    2. How often are they having diarrhea?
    3. Is there any blood or mucus in the stool?
    4. Describe the consistency?
    5. What is the volume of stool?
    6. Have you recently changed their diet? If so when did the change occur? What is the name if the old and the new food?
    7. Could they have eaten anything inappropriate? If yes, what and when?
  4. Any coughing? If yes continue to questions a-d
    1. When did it start?
    2. How often do they cough?
    3. Describe the cough? Dry/hacking, productive, high pitch wheeze
    4. Did the patient lose consciousness before, during or after the cough? If yes, for how long? Did you notice their mucus membrane color? White/pink/red/purple
  5. Any sneezing? If yes continue to questions a-d
    1. When did it start?
    2. Is it constant or intermittent?
    3. Is there any nasal discharge? If yes, clear/mucus/greenish yellow/hematuria
    4. Does your pet spend any time outside unattended?
  6. Is the patient urinating as he/she normally does? If no, continue to questions a-h
    1. When did it start?
    2. Is the change daily?
    3. Has the urine production increased or decreased?
    4. When was the last time they produced urine?
    5. Is there any straining?
    6. Do they ever posture and not produce any urine?
    7. If the odor stronger then normal?
    8. What is the color? Golden/transparent/hematuria
  7. Any change in water consumption? If yes continue to questions a-e
    1. Are they drinking more or less water?
    2. When did it start?
    3. Do they share their water bowl with another pet?
    4. How often do you change the water in one day?
    5. Has anything changed at the time of the water intake changing? Diet/weather/visitor at home/new baby/new pet/new home/vacation/prescriptions/over the counter supplements
  8. Any change in food intake? If yes continue to questions a-c
    1. Describe the change?
    2. When did it start?
    3. Has anything changed at the time the food intake changed? Diet (if diet, describe change)/weather/visitor at home/new baby/new pet/new home/vacation/prescriptions/over the counter supplements
  9. What diet are they on?
  10. Do they get snacks and if so what kind?
  11. What is the patient's exercise tolerance like? Has it changed? If yes continue to questions a-d
    1. Has their tolerance to exercise changed?
    2. In what way has it changed?
    3. When did you first notice the change?
    4. Has the change regressed, progressed or is it stable?
  12. Describe the patient's general attitude?
  13. Are you happy with their attitude?
  14. Have you seen any behavior changes? If yes continue to questions a-h
    1. Describe the change?
    2. Eliminating in the house?
    3. Having to go out to eliminate more often?
    4. No longer sleeping through the night/sleeping pattern changed?
    5. No longer coming when called?
    6. Seems depressed or has become more active?
    7. ANY sign of aggression? Please describe in detail?
    8. Have they ever taken any type of obedience training?
  15. Are there any changes in their environment?
  16. Are they taking any prescribed medication?
  17. Are they taking any OTC medications?
  18. Has the patient had any medical treatment and or surgery in another hospital? 

Some questions for ill or injured patients; pick the questions that are appropriate

  1. When did the illness/injury begin?
  2. Were you present when the injury occurred?
    1. How far did they fall?
    2. Did anything fall on top of them?
    3. Which limb if any did you notice them limp on?
  3. Did the patient lose consciousness?
  4. HBC
    1. Did the vehicle hit the patient or physically run over the patient?
    2. Was the patient ever pinned under the car or dragged by the car?
    3. Was the patient ever able to stand on their own after being hit?
  5. BW
    1. Do you know what type of animal was involved? 
    2. Did the animal pick up and/or shake your pet?
    3. Do you know the owner of the pet who did the biting?
    4. Did you get bit?
    5. Did the other animal get bit by your pet?
    6. Do you know the rabies vaccine status of the biting pet?
  6. ADR
    1. Could they have eaten something not intended for cats/dogs?
    2. Is anything missing that could have been eaten?
    3. Do they have the tendency to get into the trash?
    4. Do they have access to the trash?
    5. Do they spend time unattended outside? 
    6. Has any one changed the antifreeze on their car at a location the pet has access to?
    7. At any point did your pet seemed dazed?
    8. Did your pet relieve himself in an inappropriate place?

For further information on taking a medical history:
Small Animal Physical Diagnosis and Clinical Procedures – McCurnin and Poffenbarger
Clinical Textbook for Veterinary Technicians – McCurnin and Bassert