Questions to Ask Your Patient
Interview questions for clinicians taking a history, covering the presenting problem, medication and allergies, social circumstances, what the patient believes is wrong, and what they are willing and able to do.
20 questions, each with the reason to ask it · includes a conversation guide
The questions
Open any question to see why it works.
- 1
What made you decide to come in today, rather than last week or next month?
The trigger is often not the symptom. A new pain that has been present for months usually means something changed: a family member's diagnosis, a work requirement, a frightening search result, or the symptom finally interfering with something.
- 2
Tell me what has been happening, in your own words, from the first time you noticed something was wrong.
An uninterrupted opening account carries most of the diagnostic information and takes less time than clinicians expect. Interrupting to structure it early tends to produce a shorter, less accurate history.
- 3
What do you think is going on?
Patients frequently have a specific fear they have not mentioned, and it explains which details they emphasise. Their theory also tells you what will need addressing directly, since an explanation that never engages with it rarely reassures.
- 4
What worries you most about it?
The worst-case scenario in their mind may be unrelated to the likely diagnosis, and left unspoken it drives repeat visits. Naming it is also what makes a normal test result feel like an answer rather than a dismissal.
- 5
What is it stopping you doing?
Function is measurable and it tracks severity better than a pain score. It also gives you a specific goal to review at follow-up: back at work, sleeping through, able to climb the stairs.
- 6
When is it at its worst, and what were you doing at the time?
Timing and activity separate a lot of similar presentations, particularly for pain, breathlessness and dizziness. Ask about the last episode in detail rather than in general, because remembered patterns are often wrong.
- 7
What have you already tried, including anything not prescribed to you?
Ask this in a way that makes the answer easy: leftover antibiotics, a relative's tablets, supplements, herbal remedies and online purchases are common and rarely volunteered. What worked partially is a diagnostic clue in itself.
- 8
What are you taking now, and are there any you skip or take differently from the instructions?
Assuming some doses get missed, and saying so, gets a far more accurate answer than asking whether they are compliant. The reason matters too: cost, side effects, dosing schedule, or not believing it helps.
- 9
Have you ever had a reaction to a medicine, and what happened?
Ask for the description rather than the label, since a recorded allergy is often nausea or a family story rather than a true reaction. An inaccurate allergy record narrows treatment options for years.
- 10
Who else have you seen about this, and what were you told?
Prevents repeated investigations and reveals what the patient has understood from previous care, which is often different from what was written. It also surfaces private providers, walk-in visits and treatment abroad.
- 11
What runs in your family, and at what ages did it appear?
Ages matter as much as the conditions, since early onset in a first-degree relative changes screening decisions. Ask specifically about parents and siblings rather than accepting a general family history.
- 12
How are you sleeping, eating and getting through the day?
A single question that screens broadly and is easy to answer honestly. A change in all three at once points to something systemic, to depression, or to a burden at home that has not been mentioned.
- 13
In a typical week, how much alcohol, tobacco or anything else are you using?
Asking for a typical week gets closer to the truth than asking whether they drink. Keep your tone flat and non-reactive, since a visible response to the first answer usually ends the honest reporting.
- 14
Who is at home with you, and who helps when you are unwell?
This determines whether a treatment plan is realistic and often uncovers caring responsibilities the patient does not think are relevant. Living alone after a procedure changes what you can safely arrange.
- 15
What might get in the way of doing what we agree today?
Cost, transport, work hours, childcare, reading the label, a phone that does not receive appointment texts. Asking directly reframes a barrier as a practical problem rather than something the patient has to admit to.
- 16
How much do you want to know, and what may I say in front of your family?
Preferences differ widely, and assuming either full disclosure or protection creates avoidable harm. Ask early, record the answer, and check it again if the situation changes.
- 17
What matters most to you in how this is treated?
Fewest symptoms, fewest side effects, back to work quickly, avoiding hospital, staying independent: these lead to different reasonable plans. Without asking, clinicians tend to optimise for the outcome they would choose.
- 18
Is there anything you would not be willing to do or take?
Injections, steroids, surgery, opioids, blood products or a drug that harmed a relative. Finding the limit before you build the plan avoids a course of treatment that quietly never starts.
- 19
Would you tell me back how you are going to take this, so I can check I explained it clearly?
Putting the burden on your explanation rather than on their memory makes it possible for them to admit confusion. Errors in dose, timing and duration are common and are usually caught in this one exchange.
- 20
What have I not asked that you came in wanting to say?
The real reason for the visit frequently arrives here, at the point where the consultation appears to be ending. Ask it while still seated, because the question loses its effect once you have stood up.
Taking a history that holds up
Practical guidance for the conversation itself.
How to sequence the interview
How to sequence the interview
Open, then narrow
Begin with one open question and let the account run before moving to closed questions. Note what you want to return to rather than interrupting, and signal the shift when you start narrowing so the change of pace does not read as impatience.
Ask permission before sensitive areas
Alcohol, drug use, sexual history, violence at home and money are all better answered after a brief request. Saying that you ask everyone this, and why, raises the accuracy of the answer.
Normalise the answer you want to be told
Most people miss doses sometimes, how often does that happen for you, gets closer to the truth than asking whether they take it as prescribed. Assume the common behaviour rather than requiring a confession.
Close the loop with teach-back
Ask them to say the plan back in their own words and correct your explanation, not them. This is where dosing and follow-up errors surface, and it takes less than a minute.
When the usual questions will not work
When the usual questions will not work
- Use a professional interpreter rather than a family member, especially where consent, safeguarding or sexual health is involved.
- Ask a companion to step out at some point in the consultation, and make it routine rather than pointed, so that anything they are unable to say in front of that person can be said.
- With cognitive impairment, favour questions about routine and recent events, and confirm the history with a named informant. Record who gave which part of it.
- With children and adolescents, ask who they would like present and give them time alone if age and local practice allow.
- Check hearing, eyesight and literacy before relying on written instructions. Ask how they usually keep track of their tablets.
Common pitfalls
Common pitfalls
Closing the history too early
Fixing on a diagnosis in the first sentences narrows the questions that follow and makes contradictory information easy to miss. Keep at least one alternative in mind until the history is complete.
Stacked questions
Asking three things in one breath gets you an answer to one of them, usually the last. Ask one, wait, then ask the next.
Reacting to an answer
A raised eyebrow at a drinking figure or a missed dose ends candid reporting for the rest of the consultation and often for future ones. Keep the response neutral and follow up on the reason.
Recording a label instead of a description
Penicillin allergy, back pain and anxiety are inherited from old notes and repeated. Write what the patient described and when it happened, so the next clinician can reassess it.
Leaving the last question to the door
Concerns raised as you leave get less care than they need. Ask what has not been covered while there is still time in the appointment to act on the answer.