As a vet tech, you will often be the first person who enters an exam room with the client and patient. In addition to assessing the pet’s TPR (temperature, pulse, and respiration) and performing a brief triage exam, you will also need to collect a preliminary medical history. 

While the triage exam and TPR are important, the history is often even more valuable. Therefore, it’s important to resist the temptation to rush through it! 

What’s Included in a Medical History? 

A medical history is your opportunity to learn what the owner is observing at home, as well as about what the pet has experienced in the past. In general, the history can be broken down into four different categories:

Presenting complaint

Be sure to obtain some details. If a dog presents for diarrhea, for example, you will want to know when the diarrhea started, the nature and frequency of the diarrhea, whether the dog is straining, etc. In general, more information is better!

Other health concerns

Determine whether the pet is showing any other abnormal behaviors. Has the owner observed any coughing, sneezing, vomiting, or diarrhea? How is the pet’s appetite and energy level? Any changes in their daily routine or elimination habits? 

Previous medical history 

In the case of a new patient, it’s important to ask about the pet’s previous medical history. Has the pet experienced any serious illnesses or injuries in the past? Are there any chronic concerns? If you have seen the pet before, it’s still important to ask whether the pet has been treated elsewhere since their last visit to your hospital.

Current medications

When you ask owners whether their pet is taking medications, take the time to explore their answer a bit. Owners often forget over-the-counter medications, nutraceuticals, or homeopathic remedies unless they are specifically asked about these types of treatments. 

5 Tips for Obtaining a Thorough Patient History 

While it’s important to know what’s included in a medical history, it’s also important to know the right way to collect this information. Follow these five tips to get the most out of your patient history.

1. Start with open-ended questions 

In many veterinary practices, there is a constant sense of time pressure. This can create the temptation to rely on closed-ended questions, in order to be more efficient. In reality, though, this strategy rarely works. Open-ended questions allow you to zero in on relevant information more quickly and increase the likelihood that you will hear all of the client’s concerns. 

When asking a client about their pet’s diarrhea, don’t begin with a rapid-fire game of 20 questions. (We’ve all heard this: When did it start? Did he have a recent diet change? Is his stool watery? Soft? Formed? Does he ask to go out more often? etc.) Instead, start with a general, open-ended question: “Can you tell me a little bit about Ralphie’s diarrhea?” The owner will probably talk for a minute or two, sharing everything they consider to be relevant. Next, you can follow up with more specific, closed-ended questions, depending on what they have told you and what information they may have left out.

2. Use your active listening skills 

If it’s an especially busy day, you may be tempted to multi-task by obtaining your patient’s history as you assess their TPR. Resist this temptation! Give the history your full focus. 

Use active listening strategies to show the owner that they have your full attention, in order to elicit more information and build their trust. Avoid interrupting; if necessary, take brief notes so you can remember questions that may occur to you. When the client pauses, paraphrase what they have told you to be sure that you understand correctly. Additionally, use nonverbal cues that indicate interest, such as eye contact, nodding, and open body language.

3. Update the pet’s lifestyle information

Preventive care recommendations are typically based on a pet’s lifestyle. In many cases, though, we assess those relevant lifestyle factors once, during a pet’s initial visit, and never revisit the topic again. This results in the pet being forever vaccinated and administered parasite prevention based on this initial assessment, even if the pet’s lifestyle changes.

Don’t forget to ask about lifestyle factors at every visit, so that a pet’s preventive care routine can be updated if necessary. If you learn of a lifestyle change that impacts preventive care recommendations, be sure to document this in the medical record!

4. Ask about behavior

Behavior problems are not only frustrating, they can even lead to euthanasia or pet relinquishment. Therefore, it’s important for veterinary teams to be proactive in identifying and addressing behavioral concerns. If you wait for clients to become frustrated enough to seek your help, it may be too late to maximize your chances of a successful outcome. 

When obtaining your history, be sure to ask about behavioral issues. You can begin with a general question about the pet’s behavior, but also consider asking more specific questions. You may ask a dog owner whether their dog is fully housetrained, friendly with strangers, and/or friendly with other dogs. Ensure that your feline patients are using the litter box appropriately and not showing any destructive tendencies. Your goal is to identify little problems before they become big problems.

5. Let the client be the one to end the history conversation

During my time in practice, I noticed that the question “Is there anything else we need to address today?” was often met with a response of “no.” In contrast, if I asked “what else can you think of that we need to address today?” clients would take a moment to think, frequently coming up with one more question or concern. It’s a small thing, but reframing your history closing line in this way may minimize the likelihood of additional concerns arising later in the appointment (at a less opportune time). 

It’s only natural to feel tempted to rush through a medical history, especially if you are working in a very busy practice. Make a conscious decision to avoid this temptation! Taking a thorough history is an essential part of providing appropriate quality care for your patients. By using good communication skills and asking relevant questions, you can improve the quality of care that you offer to your patients and clients.