CHAPTER 1 The History
The following outline of a patient history is a guideline and should not be considered a rigid structure. You are beginning your relationship with the patient at this point. Take care with this relationship. The information you gain in the history loses meaning if your bond with the patient is less than strong. Choose a comfortable setting and help the patient get settled. Maintain eye contact and use a conversational tone. Begin by introducing yourself and explaining your role. Help the patient understand why you are building the history and how it will be used. Explore positive responses with additional questions: Where, when, what, how, and why. Be sensitive to the patient’s emotions at all times. Avoid confrontation and asking leading questions.