Note of the easiest approaches to history taking the "SOCRATES" Approach:

"S" stands for Site

"O" stands for onset

"C" Stands for character

"R" stands for Radiation

"A" stands for Associated symptoms

"T" Stands for timing

"E" stands for Exacerbating/relieving factors

"S" stands for severity

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This approach applies to various chief complaints were you can eliminate/replace any of these "letters" when appropriate.

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Lets Begin...

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1) Introduce yourself to the patient and explain that you will be asking them questions to better assess their health condition.

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2) Ask about the Chief Compliant: "What brings you in today?" start with an open ended questions to build rapport and have a better understanding of the patients feelings... Always show empathy..

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3) Go ahead with SOCRATES:

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Site:

• Can you point exactly where the pain/rash etc.. is? (can be eliminated)

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Onset:

• When did you first notice it? 

• Was it sudden or gradual (+/- what were you doing when it first happened)

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Character:

• Can you describe the pain for me? 

• If they couldn't describe it proceed by asking if the pain is sharp, dull, burning etc..

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Radiation: (Use the words "spread" or "shoot" to refrain from medical jargon)

• Does it shoot somewhere else?

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Associated Symptoms: List of symptoms that the differential diagnosis might cause... Depends on the scenario but always rule out red flags:

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• Any Weight loss, night sweats, fever, loss of appetite?

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Timing:

• Is it the first time you experience such symptoms?

• Is it getting worse overtime?

• Is it continuous or does it come and go (Ask about # of episodes and how long do they last for)

• Does it occur at a particular time of the day/night?

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Exacerbating/relieving factors:

• Anything that worsens the pain?

• Anything that makes it better?

• Any triggers

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Severity: 

• On a scale from 1 to 10, 1 being the least pain you ever felt and 10 being the most pain you ever felt, where do you scale this pain?

• Incase the Chief complain is not about pain ask if it interferes with their function or sleep.

• Always show empathy.

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Transition by saying "Now i will asking few more questions about your past medical history"

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Past medical history:

• Any chronic medical conditions (DM II, HTN, HLD etc..)

• Any surgeries

• Recent hospitalizations or blood Transfusions

• Are their Vaccinations up to date?

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Family history:

• Any diseases that run in the family (DM II, HTN, ACS etc..)

Medications:

• Are you on any prescriptions?

• Any over the counter medications

• Any herbal remedies?

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Social: Tell the patient that you will be asking some personal questions before proceeding.

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• Are you sexually active

• Do you Smoke/drink/use recreational drugs

• How's your diet

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End by Summarizing the history and thanking the patient!

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