While not ideal, it is often necessary to perform a "quick and dirty" past medical and minimal social history as part of a focused history and physical exam. This is particularly true in ambulatory care settings where new patients are seen for acute problems without the benefit of a thorough interview. The following is a suggested format for taking a brief past medical history in less than a minute for the average patient. (Patients with multiple chronic problems will take longer.)
Translation: Allergic to penicillin, Taking the medication Zantac, No major medical problems, Has had tubal ligation surgery, Unknown immunization status, Has smoked 1 pack per day for 10 years, Uses alcohol occasionally, No street drugs, Last menstrual period 8/15/94 and normal, Last Pap smear 2 years ago and normal, Single heterosexual partner, Tubal for contraception, Has been pregnant twice and delivered twice, Divorced, etc.