The components of the medical interview and encounter are:
Chief complaint (cc): the reason for the current medical visit. these are the ‘symptoms.’ They are in the patient’s own words and are recorded along with the duration of each one. Also called ‘presenting complaint.’
HPI or History of present illness/complaint (sometimes referred to as “ill-health” or “ailment”), a state of poor health: the chronological order of events of symptoms and further clarification of each symptom.
Current activity: occupation, hobbies, what the patient actually does.
Medications (Rx), also referred to as “pharmaceutical drug” or “medicine,” loosely defined as any chemical substance intended for use in the medical diagnosis, cure, treatment, or prevention of disease: what drugs the patient takes including prescribed, over-the-counter (OTC, medicines that may be sold directly to a consumer without a prescription from a healthcare professional, as compared to prescription drugs, which may be sold only to consumers possessing a valid prescription; and home remedies (a treatment to cure a disease or ailment that employs certain spices, vegetables, or other common items), as well as alternative and herbal medicines/herbal remedies (“herbalism,” the study and use of medicinal properties of plants). Allergies, or the hypersensitivity disorder of the immune system, are also recorded.
Past medical history (PMH/PMHx): concurrent medical problems; past hospitalizations and operations; injuries; past infectious diseases, also known as “transmissible diseases” or “communicable diseases,” comprising clinically evident illness (i.e., characteristic medical signs and/or symptoms of disease) resulting from the infection, presence and growth of pathogenic biological agents in an individual host organism; and/or vaccinations, or the administration of antigenic material (a vaccine) to stimulate an individual’s immune system to develop adaptive immunity to a pathogen; history of known allergies.
Social history (SH): birthplace, residences, marital history, social and economic status, habits (including diet (which in nutrition is the sum of food consumed by a person or other organism), medications, tobacco smoking (the practice of burning tobacco and inhaling the resulting smoke consisting of particle and gaseous phases), alcohol).
Family history (FH), which in medicine consists of information about disorders from which the direct blood relatives of the patient have suffered: listing of diseases in the family that may impact the patient. A family tree, or pedigree chart, a chart representing family relationships in a conventional tree structure, is sometimes used.
Review of systems (ROS) or “systems inquiry”: a set of additional questions to ask, which may be missed on HPI; a general enquiry (have you noticed any weight loss, change on sleep quality, fevers, lumps and bumps? etc.), followed by questions in the body’s main organ systems–the human heart, an organ that provides a continuous blood circulation through cardiac cycle and is one of the most vital organs in the human body; the human lungs, the organs of respiration in humans; the human gastrointestinal/digestive tract, the stomach and intestine, sometimes including all the structures from the mouth to the anus; the urinary tract/renal system, the organ system that produces, stores, and eliminates urine; etc.