Hospitalizations: including all medical, surgical, and psychiatric hospitalizations. Note the date, reason, duration for the hospitalization.
Injuries, or accidents: note the type and date of injury.
Surgeries: note the type of procedure, date, hospital, surgeon, and any complications.
Current medications: note name, dosage, frequency of any medication, including any over-the-counter medications and herbal remedies. Note whether patient is taking the medications according to the prescribed instructions.
Diet: ask about everything the patient has eaten the day before and for the past week. Note the type of food consumed and do a nutritional status assessment. Medically, however, this is considered to be a part of social history. Dietary supplements would also be under PMH.
Sleep: a useful mnemonic for sleep patterns is BEARS, for Bedtime problems, Excessive daytime sleepiness, Awakenings at night, Regularity and duration of sleep, Snoring.
Growth and development: plots of height, weight, and head circumference are standard content for pediatric records, any change in trajectory, developmental mile stones, any IQ or other developmental testing
Acronyms
Several acronyms have been developed to categorize the appropriate questions to include:
"MMASH", for Medical Illnesses, Medications, Allergies, Surgeries, Hospitalizations.
"PAM HUGS FOSS", for
*Previous presence of the symptom
*Allergies
*Medicines
*Hospitalization for any illness in the past
*Urinary changes
*Gastrointestinal complaints
*Sleep pattern
*Family history
*OB/GYN history
*Sexual habits
*Social life
In prehospital medicine, namely EMS, the acronyms SAMPLE or CHAMPS are used.
Signs/Symptoms
Allergies
Medicines
Past Pertinent History
Last bowel movement/oral intake
Events leading to the current complaint
Chief Complaint
History
Allergies
Medicines
Previous activity
Signs/Symptoms
Medicare definitions
The Centers for Medicare and Medicaid Services has published criteria for what constitutes a reimbursable PMH. A PMH is considered one of three elements of the "Past, Family, and Social History" :
Past medical history: "the patient's past experiences with illnesses, operations, injuries and treatments";
Family history: "a review of medical events in the patient's family, including diseases which may be hereditary or place the patient at risk";
Social history: "an age-appropriate review of past and current activities".
A pertinent PFSH consists of at least one of the three components; a full PFSH consists of two or three components for an established patient, or all three components for a new patient visit.
