OSCE Station: Generic Disease History Checklist

1. Introduction

• Wash hands, PPE if appropriate
• Introduce yourself: name and role
• Confirm patient name and date of birth
• Explain: “I’d like to ask some questions about your problem and general health.”
• Gain consent
• Ensure comfort, privacy, and ask about pain

2. Presenting Complaint

• Start open: “What has brought you in today?”
• Clarify main symptom(s)
• Duration: “How long has this been happening?”

3. History of Presenting Complaint

• Site: Where is it?
• Onset: When did it start? Sudden or gradual?
• Character: What does it feel like?
• Radiation: Does it spread anywhere?
• Associated symptoms: Any other symptoms?
• Timing: Constant or intermittent? Progression?
• Exacerbating/relieving factors: What makes it worse or better?
• Severity: Score out of 10; impact on function/sleep/work.

• Previous episodes and investigations/treatment
• Relevant red flags
• Effect on activities of daily living
• Patient’s ideas, concerns, and expectations: “What do you think is causing this?” “What are you most worried about?” “What were you hoping we could do today?”

4. Systemic Enquiry

• Fever, weight loss, fatigue, appetite change, night sweats

• Chest pain, breathlessness, palpitations, cough, wheeze, oedema

• Nausea, vomiting, abdominal pain, bowel change, bleeding, jaundice

• Urinary symptoms, haematuria, frequency, dysuria
• Menstrual, sexual, and pregnancy history when relevant

• Headache, weakness, sensory change, dizziness, seizures, visual/speech changes

5. Past Medical and Surgical History

• Medical conditions, including relevant risk factors
• Previous admissions
• Operations or procedures
• Previous similar symptoms
• Mental health conditions where relevant

6. Drug and Allergy History

• Prescribed medicines, doses, adherence
• Over-the-counter and herbal medications
• Recent medication changes
• Allergies and the exact reaction

7. Family History

• Relevant familial disease
• Age of onset and cause of death where relevant

8. Social History

• Occupation and occupational exposures
• Home situation, support, independence with daily activities
• Smoking: type, amount, duration, pack-years
• Alcohol: units per week
• Recreational drugs
• Diet, exercise, travel, animals, sexual history, safeguarding, depending on case

9. Close

• Summarise key points
• Ask: “Is there anything else you think is important that I have not asked?”
• Offer chance for questions
• Thank the patient
• State next step: examination, observations, tests, or senior review