History of the Illness
You should describe the story of your main concern in your own words. A written history is no substitute. The manner in which you describe your symptom is as important to the doctor as the presence of the symptom itself.
- State when and how the symptom began.
- Where is it located?
- Is it steady or does it come and go?
- Does eating, exercise, traveling, stress, or other factors make it worse or better?
- How does it interfere with your life, job, or personal relationships?
- Are there associated symptoms – for example, diarrhea, headache, or blurred vision?
- What diagnosis, if any, have you already received for this? While it is OK to venture your own diagnosis, it is essential that the doctor make up his or her own mind.
- What treatments, if any, have you undergone?
It is important to describe all factors that might bear on the concern, but too much information can be counter-productive. The healthcare provider should help here by prompting or steering the conversation back to the point.
If there are two unrelated problems, deal with them one at a time to avoid confusion.
Keep in mind that time is valuable and avoid digressions.
Do not be shy. If there is a gut problem, a detailed description of your defecation pattern and the nature of the stool is vital information. Similarly, the nature of your urine and other bodily discharges are sometimes keys to diagnosis. Sexual habits may also be important. Indeed omission of such information can delay diagnosis. No healthcare professional will laugh or disapprove of your description. Remember, they deal with such material daily.