Taking a Medical History


 Build a rapport to create trust  

 Find your own style and approach 

 Be flexible and adapt your approach for each patient 

 Be self-aware so you can recognise when to adapt your style 

 Spend time refining your approach as this is a key part of most diagnosis making â± 


Be conversational 

 Be friendly ðŸ˜„

 Make the patient feel comfortable 


Set boundaries 

 Attire: wear appropriate clothes and a name badge 

 Introduction: greet the patient and introduce yourself and why you are there 

 Gain consent: make sure the patient wishes to go ahead âœ… 

 Confidentiality: what the patient tells you is confidential (the only exception is if they or someone else is at risk – you must inform the patient of this) 

 Time: tell the patient how much time you have â± 


Gain patient trust

 Be honest  

 Be yourself 

 The patient will trust you if you do so 


The consultation 

 Cues: recognise verbal/non-verbal cues 

 Introduction: they may have rehearsed this, everything after this is conversational 

 Utilise silence: the patient may try to fill silences 

 Ask questions: e.g. ask if they have any questions❓ 

 Listen actively: nod and respond where appropriate 

 Summarise: summarise what they tell you back to them 

 Body language: face them, make eye contact, and show real interest ðŸ‘


Coaching style questions❓

 e.g. smoking cessation – ask questions such as “why do you want to change? How much do you want to change? What could be a barrier to change?” 


Remind the patient of the key points 

 Repeat the key points at the end ðŸ”„ 

 Ask them to repeat them back to you 

 Invite them to make notes âœ  

 Give them written information ðŸ“‘

 Show them where they can find more information ðŸ“‘

 Check they understand the information given  

 Tell them they can ask you or a colleague any questions they think of after the consultation❓ 



 Be aware of your own feelings, as consultations can be distressing 

 Make sure to be kind to yourself and the patient 


  1. Build a rapport by being conversational
  2. Ask appropriate questions
  3. Set boundaries
  4. Your non-verbal actions are as important as what you say
  5. Reiterate key points

About the author

The i-medics Editorial Team consists of Doctors, Medical Students, Professional Content writers, i-medics Ambassadors and Freelance workers.