Medical/Surgical History

A comprehensive history taking or review of systems is very similar to the approach that is taken with any adult patient. Take special care to ask about under reported issues (bowel and bladder, falls, pain, alcohol use). 

Screening:

  • Comprehensive: Ask about prescription medications, over the counter medications, herbal remedies, eye drops, inhalers, vitamins and supplements and PRN frequency. Have the patient gather all of their meds and bring them to the appointment in a plastic bag. Gather collateral information from family/friend caregivers and other health providers and medical records.
  • Compliance: Explore how the patient manages the medications (individual bottles, dosette box and who fills it, blister packs). Do they ever miss doses, what do they do if so?
  • Address of pharmacy: Do they deal with multiple pharmacies?
  • Vaccinations: Flu, pneumovax, shingles


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