School of Medicine

History Evaluation

Master
Content

Following a "performance," the standardized patient completes a history evaluation form. Below is a sample history evaluation form.

Heading

Patient-Centered Process

Content

( ) Yes ( ) No Appropriate introduction/greeting

( ) Yes ( ) No Began with and used other open-ended questions

( ) Yes ( ) No Used closed-ended questions for clarification

( ) Yes ( ) No Avoided complex or leading questions

( ) Yes ( ) No Avoided multiple questions

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Facilitating Skills

Content

( ) Yes ( ) No Speech clear

( ) Yes ( ) No Language clear (no jargon)

( ) Yes ( ) No Avoided disruptive Note-taking

( ) Yes ( ) No Attended to patient’s non-verbal communication

( ) Yes ( ) No Used silence and nonverbal encouragement

( ) Yes ( ) No Used facilitative techniques (echoing, reflection, neutral utterances, paraphrasing)

( ) Yes ( ) No Used emotion-handling skills during interview (understanding/legitimation, respecting/praising, supporting/partnership)

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History of Present Illness

Content

( ) Yes ( ) No Chief complaint in patient’s own words

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Symptoms Patient Experiencing

Content

( ) Yes ( ) No Location

( ) Yes ( ) No Radiation

( ) Yes ( ) No Character

( ) Yes ( ) No Severity

( ) Yes ( ) No Associated Symptoms

( ) Yes ( ) No Onset

( ) Yes ( ) No Duration

( ) Yes ( ) No Aggravating factors

( ) Yes ( ) No Relieving factors

( ) Yes ( ) No Impact of illness on patient and others

( ) Yes ( ) No Patient’s concerns about illness

( ) Yes ( ) No Health issues (ethical-social-spiritual, functional, health promotion, health hazards)

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Past Medical History

Content

( ) Yes ( ) No Hospitalizations

( ) Yes ( ) No Other medical problems

( ) Yes ( ) No Major diseases

( ) Yes ( ) No Medications

( ) Yes ( ) No Allergies

( ) Yes ( ) No Menstrual/OB history

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Personal/Social History

Content

( ) Yes ( ) No Current personal situation

( ) Yes ( ) No Other personal factors (smoking, alcohol)

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Family History

Content

( ) Yes ( ) No Family history of present illness

( ) Yes ( ) No Specific diseases (diabetes, hypertension, high cholesterol)

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Review of Systems

Content

( ) Yes ( ) No Review of systems (questions related to the function of relevant systems)

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Transition to Physical Exam

Content

( ) Yes ( ) No Summarized history

( ) Yes ( ) No Asked patient if she/he had any questions

( ) Yes ( ) No Answered patient’s questions clearly

( ) Yes ( ) No Appropriate transition to physical exam

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Global Assessment

Content

Overall, how satisfied were you with this student’s history taking skills?

( ) extremely dissatisfied
( ) very dissatisfied
( ) dissatisfied
( ) satisfied
( ) very satisfied
( ) extremely satisfied

Heading

Global Assessment

Content

Overall, how satisfied were you with this student’s history taking skills?

( ) extremely dissatisfied
( ) very dissatisfied
( ) dissatisfied
( ) satisfied
( ) very satisfied
( ) extremely satisfied