Triage Questions to Ask Patients
Triage questions for nurses and emergency department staff, in the order they are usually needed: presenting complaint and onset, the screen for immediate threats to life, then the history that changes what happens next.
The questions
Open any question for the note
What brings you in today, and when exactly did it start?
Why ask it
Take the complaint in the patient's own words and record it that way, because paraphrasing into a diagnosis fixes everyone's thinking early. Sudden onset that the patient can time to the minute is a different problem from something that has built over four days.
Are you having chest pain, difficulty breathing, or the worst headache you have ever had?
Why ask it
One question covering the presentations that cannot wait in the queue. Ask it of everyone, including patients who came in for something apparently unrelated, and act on a yes before completing the rest of the history.
Any weakness, numbness, trouble speaking or drooping on one side, and when were you last completely well?
Why ask it
The time the patient was last well, not the time symptoms were noticed, is what determines which treatments remain available. If they woke with symptoms, record the time they went to sleep and say so explicitly in the note.
How bad is the pain right now, from nought to ten, and what was it at its worst?
Why ask it
The current score alone underestimates a patient who has taken analgesia or whose pain comes in waves. Both numbers, plus the time of the worst episode, give the next clinician something to compare against.
Where is the pain, does it move anywhere, and what makes it better or worse?
Why ask it
Radiation, and change with movement, breathing or eating, separate several serious causes from each other at the door. Pain that is worse on exertion and eased by rest deserves attention even when the patient calls it indigestion.
Any confusion, dizziness, fainting, or has anyone told you that you have not seemed yourself?
Why ask it
Altered mental status is easily missed in a brief conversation, particularly in older patients. Ask whoever came in with them, since family notice a change days before it appears in any observation chart.
Have you had a fall, a blow to the head, or any other injury recently?
Why ask it
A minor-sounding fall matters a great deal in a patient on anticoagulants, in anyone over sixty-five, and in anyone who cannot remember the event. Ask what they were doing at the time, because the cause of the fall is sometimes the real presentation.
Have you had fever or chills, and have you taken anything that would bring a temperature down?
Why ask it
Paracetamol or ibuprofen taken an hour ago can mask a fever entirely. Combine the answer with heart rate, breathing rate and how unwell they look rather than relying on the recorded temperature.
What medicines do you take, including anything over the counter, inhalers, injections and blood thinners?
Why ask it
Anticoagulants, insulin, steroids, beta blockers and immunosuppressants each change urgency or interpretation. Beta blockers can keep the heart rate unremarkable in a patient who is genuinely unwell, so treat a normal pulse with caution here.
Do you have any allergies to medicines, food or latex, and what happens when you are exposed?
Why ask it
The reaction matters as much as the substance: a rash and an airway problem belong in different parts of the record. Document the reaction itself so nobody later treats an intolerance as an absolute contraindication or the reverse.
Do you have any ongoing conditions such as diabetes, heart, kidney or lung disease, or a weakened immune system?
Why ask it
These change both risk and presentation. Diabetic patients may have a painless cardiac event, and immunosuppressed patients can be seriously infected without a fever, so the same complaint carries more weight.
Is there any chance you could be pregnant, and when was your last period?
Why ask it
Ask every patient of childbearing age, privately, regardless of what they have told you about contraception. The answer changes imaging, medication and the differential, and ectopic pregnancy presents as abdominal pain or collapse.
Any nausea, vomiting or diarrhoea, and have you been able to keep fluids down?
Why ask it
Ability to keep fluids down is the practical measure, more useful than counting episodes. Ask about the last time they passed urine, which is the quickest indicator of how dry they are.
Any change in passing urine or in your bowels, and have you seen any blood in either?
Why ask it
Retention, no urine output at all, and blood each need to be flagged rather than filed. Patients frequently withhold this until asked directly, so ask directly and without commentary.
Is there any bleeding that will not stop, or bruising you cannot explain?
Why ask it
Take this together with the medication answer, since a patient on anticoagulants with new bruising or a head injury needs to be moved up regardless of how well they look. Unexplained bruising in a well patient also warrants a quiet safeguarding thought.
Have you had any surgery, procedure or hospital admission in the last few weeks?
Why ask it
Recent procedures raise the possibility of infection, bleeding and clots, and recent immobility does the same. Ask what was done and when, not just whether they have been in hospital.
Have you travelled recently, or been around anyone with the same symptoms?
Why ask it
Determines both isolation and the differential, and a positive answer usually needs acting on before the patient sits down in a full waiting room. Ask where, not just whether.
Do you drink alcohol or use tobacco or other drugs, and when did you last use anything?
Why ask it
Asked plainly and without reaction, this gets a more honest answer than a form does. The timing of last use predicts withdrawal, which can begin during a long wait, and it affects sedation and analgesia decisions.
Have you had this before, and what was it that time?
Why ask it
Patients with a known pattern are often right about what is happening, and a documented prior diagnosis saves considerable time. Be careful with the opposite too: this time being different from the usual episode is a warning worth recording.
Is there anything else you think we should know, or anything you are particularly worried about?
Why ask it
This catches what the structured questions missed, and it is where patients disclose the symptom they were embarrassed to lead with. A patient who says they feel like something is badly wrong should be believed and reassessed rather than reassured.
Working Through a Triage Assessment
Practical guidance for the conversation itself
Practice at the Front Door
Look before you ask
Airway, breathing, circulation, disability and exposure come before history taking. Colour, work of breathing, speech in full sentences and whether the patient can walk in tell you more in ten seconds than the next five questions will.
Record their words, not your interpretation
Write the complaint as spoken and keep observations separate from conclusions. A triage note that already contains a diagnosis narrows what the next clinician considers.
Reassess anyone still waiting
Patients deteriorate in waiting rooms, and the first set of observations only describes the moment it was taken. Set an interval for repeat checks and note who is responsible for them.
Use an interpreter rather than a relative
Family members summarise, soften and sometimes answer on the patient's behalf. Where safeguarding or intimate symptoms are in question, a professional interpreter is a clinical requirement rather than a courtesy.
Findings That Should Not Wait
- 1Chest pain or pressure, particularly with sweating, nausea or breathlessness.
- 2Respiratory distress, unable to speak in full sentences, or falling oxygen saturation.
- 3Sudden severe headache, or focal neurological signs with a known time last well.
- 4Uncontrolled bleeding, or any bleeding in a patient on anticoagulants.
- 5New confusion, drowsiness or a change in level of consciousness.
- 6Signs of shock: low blood pressure, fast heart rate, cold or mottled skin, poor urine output.
- 7Suspected anaphylaxis, including any airway or breathing involvement after exposure.
- 8Suicidal intent, or acute agitation with risk to the patient or others.
- 9Abdominal pain with collapse or possible pregnancy.
- 10Fever with a rash that does not blanch, or with an immunosuppressed patient.
How Triage Goes Wrong
Anchoring on the presenting complaint
The reason a patient gives for attending is where the assessment starts, not where it ends. Ask the immediate-threat questions of everyone, including the patient who came in about a wrist.
Trusting normal observations too far
Older patients, diabetic patients and those on rate-controlling medication can look stable while seriously unwell. Weigh how the patient appears alongside the numbers.
Dismissing a patient's own alarm
People who say this is not like the usual episode, or that something feels badly wrong, are frequently right. Record the statement and treat it as a reason to reassess.
Letting frequent attenders lose the benefit of the doubt
A familiar patient with a familiar complaint still needs the same screen. The presentation that gets missed is usually the one everybody assumed they already understood.
Assessing intimate or safeguarding concerns within earshot
Pregnancy, drug use, injuries and fear of someone at home cannot be asked about honestly in a corridor. Move the patient, or ask again once you are alone with them.