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{{Short description|Patient information gained by a physician}}
{{Short description|Patient information gathered by a physician}}
{{Distinguish|History of medicine}}
{{Distinguish|History of medicine}}
{{For|the journal|Medical History (journal)}}
{{For|the journal|Medical History (journal)}}
The '''medical history''', '''case history''', or '''anamnesis''' (from Greek: ἀνά, ''aná'', "open", and μνήσις, ''mnesis'', "memory") of a [[patient]] is a set of information the [[physician]]s collect over medical [[interview]]s. It involves the patient, and eventually people close to them, so to collect reliable/objective information for managing the [[medical diagnosis]] and proposing efficient [[medical treatment]]s. The medically relevant complaints reported by the patient or others familiar with the patient are referred to as [[symptom]]s, in contrast with [[sign (medicine)|clinical signs]], which are ascertained by direct examination on the part of medical personnel. Most health encounters will result in some form of history being taken. Medical histories vary in their depth and focus. For example, an [[ambulance]] [[paramedic]] would typically limit their history to important details, such as name, history of presenting complaint, allergies, etc. In contrast, a [[psychiatric history]] is frequently lengthy and in depth, as many details about the patient's life are relevant to formulating a management plan for a [[Psychiatry|psychiatric]] illness.
The '''medical history''', '''case history''', or '''anamnesis''' (from Greek: ἀνά, ''aná'', "open", and μνήσις, ''mnesis'', "memory") refers to the information collected by a [[physician]] from a [[patient]] during a medical [[interview]]. It serves as a fundamental component in assessing the patient's condition, guiding [[medical diagnosis]], and formulating appropriate [[medical treatment]]s.


The information obtained in this way, together with the physical examination, enables the physician and other [[health professionals]] to form a [[diagnosis]] and [[therapy|treatment]] plan. If a [[diagnosis]] cannot be made, a provisional diagnosis may be formulated, and other possibilities (the [[differential diagnosis|differential diagnoses]]) may be added, listed in order of likelihood by convention. The treatment plan may then include further investigations to clarify the diagnosis.
Medical history is typically obtained through direct questioning of the patient, and when necessary, from close relatives or caregivers to ensure reliable and objective information. The patient's self-reported issues are classified as [[symptom]]s, while findings discovered through direct examination by medical professionals are referred to as [[sign (medicine)|clinical signs]].


The method by which doctors gather information about a patient's past and present medical condition in order to make informed clinical decisions is called the history and physical ({{a.k.a.}} the H&P). The history requires that a clinician be skilled in asking appropriate and relevant questions that can provide them with some insight as to what the patient may be experiencing. The standardized format for the history starts with the chief concern (why is the patient in the clinic or hospital?) followed by the history of present illness (to characterize the nature of the symptom(s) or concern(s)), the past medical history, the past surgical history, the family history, the social history, their medications, their allergies, and a review of systems (where a comprehensive inquiry of symptoms potentially affecting the rest of the body is briefly performed to ensure nothing serious has been missed).<ref>{{cite web|title=Patient Responsibilities|publisher=American Medical Association|url=https://www.ama-assn.org/delivering-care/ethics/patient-responsibilities|access-date=24 October 2020}}</ref> After all of the important history questions have been asked, a focused physical exam (meaning one that only involves what is relevant to the chief concern) is usually done. Based on the information obtained from the H&P, lab and imaging tests are ordered and medical or surgical treatment is administered as necessary.
The depth and focus of a medical history vary depending on the context. For example:
* An [[ambulance]] [[paramedic]] may only gather essential details such as name, history of the presenting complaint, and [[allergies]].
* A [[psychiatric history]] is often extensive, involving many aspects of the patient’s life to formulate an effective management plan for a [[psychiatric disorder]].


==Process==
A comprehensive history, combined with a physical examination, helps healthcare providers establish a [[diagnosis]] and develop an appropriate [[treatment plan]]. If a conclusive diagnosis is not immediately possible, a [[provisional diagnosis]] is formulated, and further diagnostic testing may be ordered to narrow down potential conditions (the [[differential diagnosis]]).
[[File:Hx in PEDz.pdf|Example|thumb|right]]


A practitioner typically asks questions to obtain the following information about the patient:
== History and Physical (H&P) ==
The history and physical (H&P) is the standard method by which physicians collect and organize patient information to support clinical decision-making. The history involves structured questioning, while the physical examination focuses on relevant clinical findings.


* Identification and [[demographics]]: name, age, height, weight.
A typical medical history follows a standardized structure:
* The "[[chief complaint]] (CC)" – the major health problem or concern, and its time course (e.g. chest pain for past 4 hours).
# Chief complaint (CC): The primary reason for the patient’s visit.
* [[History of the present illness]] (HPI) – details about the complaints, enumerated in the CC (also often called ''history of presenting complaint'' or HPC).
# History of present illness (HPI): A detailed exploration of the current complaint.
* [[Past medical history]] (PMH) (including major illnesses, any previous surgery/operations (sometimes distinguished as ''past surgical history'' or PSH), any current ongoing illness, e.g. diabetes).
# Past medical history (PMH): Previous illnesses, hospitalizations, and ongoing medical conditions.
* [[Review of systems]] (ROS) Systematic questioning about different [[organ system]]s
# Past surgical history (PSH): Record of previous surgeries and operations.
* [[Family history (medicine)|Family diseases]] – especially those relevant to the patient's chief complaint.
# Family history (FH): Genetic and hereditary conditions relevant to the patient's health.
* [[List of childhood diseases|Childhood diseases]] – this is very important in [[pediatrics]].
# Social history (SH): Lifestyle factors such as occupation, living arrangements, smoking, alcohol use, and recreational drug use.
* [[Social history (medicine)]] – including living arrangements, occupation, marital status, number of children, drug use (including tobacco, alcohol, other [[recreational drug use]]), recent foreign travel, and exposure to environmental pathogens through recreational activities or pets.
# Medication history: Current and past medications, including [[over-the-counter drug]]s and [[alternative medicine]].
* Regular and acute [[medications]] (including those prescribed by doctors, and others obtained over-the-counter or [[alternative medicine]])
# Allergies: Drug, food, and environmental allergies.
* [[Allergy|Allergies]] – to medications, food, latex, and other environmental factors
# Review of systems (ROS): A systematic assessment of symptoms affecting different organ systems.
* [[Human sexuality|Sexual]] history, [[obstetric]]/[[gynecological]] history, and so on, as appropriate.
* Conclusion & closure


History-taking may be ''comprehensive history taking'' (a fixed and extensive set of questions are asked, as practiced only by health care students such as medical students, physician assistant students, or nurse practitioner students) or ''iterative hypothesis testing'' (questions are limited and adapted to rule in or out likely diagnoses based on information already obtained, as practiced by busy clinicians). [[Computer]]ized history-taking could be an integral part of [[clinical decision support system]]s.
Following the history, a focused physical examination is conducted to assess the chief concern. Based on these findings, physicians may order additional [[laboratory test]]s or [[medical imaging]] to confirm a diagnosis and determine appropriate treatment.


A follow-up procedure is initiated at the onset of the illness to record details of future progress and results after treatment or discharge. This is known as a catamnesis in medical terms.
== Process ==
[[File:Hx in PEDz.pdf|thumb|right|Example of a pediatric history form]]


==Review of systems==
A practitioner typically gathers the following key details:
 
* Identification and demographics: Name, age, sex, height, weight.
* Chief complaint (CC): The primary medical issue and its duration (e.g., chest pain for four hours).
* History of present illness (HPI): Detailed description of symptoms, their onset, and progression.
* Past medical history (PMH): Previous illnesses, surgeries, chronic conditions (e.g., [[diabetes mellitus]], [[hypertension]]).
* Review of systems (ROS): Systematic questioning of different [[organ system]]s to uncover additional symptoms.
* Family history (FH): Inherited conditions and illnesses affecting close relatives.
* Childhood diseases: Particularly relevant in [[pediatrics]].
* Social history (SH): Living situation, occupation, marital status, lifestyle habits, [[recreational drug use]], exposure to infectious diseases, etc.
* Medication history: Current and past prescription and non-prescription medications.
* Allergy history: Known allergies to medications, foods, or environmental triggers.
* Sexual and gynecological history: If relevant, details about [[reproductive health]], past pregnancies, and sexually transmitted infections.
* Conclusion and follow-up: Establishing a treatment plan, scheduling further testing, or recommending specialist consultation.
 
Medical history can be collected using different approaches:
* Comprehensive history-taking: A detailed and standardized interview, often conducted by [[medical student]]s, [[physician assistant]]s, or [[nurse practitioner]]s.
* Hypothesis-driven history-taking: A more targeted approach, used by experienced clinicians to rule in or out likely diagnoses efficiently.
* Computerized history-taking: Increasingly integrated into [[electronic health record]]s, this method allows for structured and standardized patient data collection.
 
== Review of Systems (ROS) ==
{{main|Review of systems}}
{{main|Review of systems}}
Whatever [[system]] a specific condition may seem restricted to, all the other systems are usually reviewed in a comprehensive history. The review of systems often includes all the main systems in the body that may provide an opportunity to mention symptoms or concerns that the individual may have failed to mention in the history. Health care professionals may structure the review of systems as follows:
A review of systems (ROS) systematically checks for symptoms in various organ systems, ensuring that no significant medical issues are overlooked. It often includes:
 
* Cardiovascular system (chest pain, dyspnea, ankle swelling, palpitations) are the most important symptoms and you can ask for a brief description for each of the positive symptoms.
* Respiratory system (cough, haemoptysis, epistaxis, wheezing, pain localized to the chest that might increase with inspiration or expiration).
* Gastrointestinal system (change in weight, flatulence and heartburn, dysphagia, odynophagia, hematemesis, melena, hematochezia, abdominal pain, vomiting, bowel habit).
* Genitourinary system (frequency in urination, pain with micturition (dysuria), urine color, any urethral discharge, altered bladder control like urgency in urination or incontinence, menstruation and sexual activity).
* Nervous system (Headache, loss of consciousness, dizziness and vertigo, speech and related functions like reading and writing skills and memory).
* Cranial nerves symptoms (Vision (amaurosis), diplopia, facial numbness, deafness, oropharyngeal dysphagia, limb motor or sensory symptoms and loss of coordination).
* Endocrine system (weight loss, polydipsia, polyuria, increased appetite (polyphagia) and irritability).
* Musculoskeletal system (any bone or joint pain accompanied by joint swelling or tenderness, aggravating and relieving factors for the pain and any positive family history for joint disease).
* Skin (any skin rash, recent change in cosmetics and the use of sunscreen creams when exposed to sun).


==Inhibiting factors==
* Cardiovascular system: Chest pain, [[dyspnea]], [[palpitations]], ankle swelling.
Factors that inhibit taking a proper medical history include a physical inability of the patient to communicate with the physician, such as unconsciousness and [[communication disorder]]s. In such cases, it may be necessary to record such information that may be gained from other people who know the patient. In medical terms, this is known as a heteroanamnesis, or collateral history, in contrast to a self-reporting anamnesis.
* Respiratory system: [[Cough]], [[hemoptysis]], [[wheezing]], chest pain worsened by breathing.
* Gastrointestinal system: [[Abdominal pain]], [[vomiting]], [[diarrhea]], [[constipation]], [[hematemesis]].
* Genitourinary system: [[Dysuria]], changes in urine color, abnormal discharge, [[incontinence]].
* Nervous system: [[Headache]], [[dizziness]], [[loss of consciousness]], memory problems.
* Cranial nerves: [[Vision]] changes, [[facial numbness]], [[hearing loss]], difficulty swallowing.
* Endocrine system: [[Weight loss]], [[polydipsia]], [[polyuria]], changes in appetite.
* Musculoskeletal system: [[Joint pain]], [[joint swelling]], [[muscle weakness]].
* Skin: [[Rash]], recent changes in cosmetics or [[sun exposure]] reactions.


Medical history taking may also be impaired by various factors impeding a proper [[doctor-patient relationship]], such as transitions to physicians that are unfamiliar to the patient.
== Inhibiting Factors ==
Several factors may impede effective history-taking:


History taking of issues related to [[sexual medicine|sexual]] or [[reproductive medicine]] may be inhibited by a reluctance of the patient to disclose intimate or uncomfortable information. Even if such an issue is on the patient's mind, they often do not start talking about such an issue without the physician initiating the subject by a specific question about sexual or [[reproductive health]].<ref name=Quilliam2011/> Some familiarity with the doctor generally makes it easier for patients to talk about intimate issues such as sexual subjects, but for some patients, a very high degree of familiarity may make the patient reluctant to reveal such intimate issues.<ref name=Quilliam2011/> When visiting a health provider about sexual issues, having both partners of a couple present is often necessary, and is typically a good thing, but may also prevent the disclosure of certain subjects, and, according to one report, increases the stress level.<ref name=Quilliam2011>{{cite journal |doi=10.1136/jfprhc.2011.0060 |title='The Cringe Report': Why patients don't dare ask questions, and what we can do about that |year=2011 |last1=Quilliam |first1=S. |journal=Journal of Family Planning and Reproductive Health Care |volume=37 |issue=2 |pages=110–2 |pmid=21454267|doi-access=free }}</ref>
* Physical barriers: Unconsciousness, [[communication disorder]]s, or cognitive impairment.
* Psychosocial barriers: [[Language barriers]], anxiety, stress, or reluctance to disclose sensitive health information.
* Lack of continuity in care: Changing physicians may lead to fragmented patient histories.
* Cultural and personal sensitivities: Patients may hesitate to discuss [[sexual health]], [[mental health]], or substance use.


== Computer-assisted history taking ==
When patients cannot provide their own history, physicians may rely on collateral history (heteroanamnesis) from family members or caregivers.
'''Computer-assisted history taking''' or '''computerized history taking''' systems have been available since the 1960s.<ref>{{cite journal |pmid=5635452 |year=1968 |last1=Mayne |first1=JG |last2=Weksel |first2=W |last3=Sholtz |first3=PN |title=Toward automating the medical history |volume=43 |issue=1 |pages=1–25 |journal=Mayo Clinic Proceedings}}</ref> However, their use remains variable across healthcare delivery systems.<ref name="Pappas">{{cite journal |last1=Pappas |first1=Y |last2=Všetečková |first2=J |last3=Poduval |first3=S |last4=Tseng |first4=PC |last5=Car |first5=J |title=Computer-Assisted versus Oral-and-Written History Taking for the Prevention and Management of Cardiovascular Disease: a Systematic Review of the Literature. |journal=Acta Medica |date=2017 |volume=60 |issue=3 |pages=97–107 |doi=10.14712/18059694.2018.1 |pmid=29439755|doi-access=free |hdl=10044/1/69815 |hdl-access=free }}</ref>


One advantage of using computerized systems as an auxiliary or even primary source of medically related information is that patients may be less susceptible to [[social desirability bias]].<ref name="Pappas"/>  For example, patients may be more likely to report that they have engaged in unhealthy lifestyle behaviors. Another advantage of using computerized systems is that they allow easy and high-fidelity portability to a patient's [[electronic medical record]].
== Computer-Assisted History Taking ==
Also an advantage is that it saves money and paper.
{{main|Computer-assisted history taking}}
'''Computer-assisted history taking''' systems have been developed since the 1960s to enhance efficiency and accuracy. These systems allow patients to enter medical information electronically before their appointment.


One disadvantage of many computerized medical history systems is that they cannot detect non-verbal communication, which may be useful for elucidating anxieties and treatment plans. Another disadvantage is that people may feel less comfortable communicating with a computer as opposed to a human. In a sexual history-taking setting in Australia using a computer-assisted self-interview, 51% of people were very comfortable with it, 35% were comfortable with it, and 14% were either uncomfortable or very uncomfortable with it.<ref>{{cite journal |doi=10.1136/sti.2006.020776 |title=A randomised controlled trial comparing computer-assisted with face-to-face sexual history taking in a clinical setting |year=2006 |last1=Tideman |first1=R L |last2=Chen |first2=M Y |last3=Pitts |first3=M K |last4=Ginige |first4=S |last5=Slaney |first5=M |last6=Fairley |first6=C K |journal=Sexually Transmitted Infections |volume=83 |pages=52–6 |pmid=17098771 |issue=1 |pmc=2598599}}</ref>
'''Advantages:'''
* Reduces social desirability bias, leading to more honest reporting of lifestyle habits.
* Integrates seamlessly with [[electronic medical records]] for easy access.
* Saves time and reduces paperwork.


The evidence for or against computer-assisted history taking systems is sparse. As of 2011, there were no [[randomized control trial]]s comparing computer-assisted versus traditional oral-and-written family history taking to identifying patients with an elevated risk of developing [[Diabetes mellitus type 2|type 2 diabetes mellitus]].<ref>{{cite book |doi=10.1002/14651858.CD008489.pub2 |pmid=22161431 |chapter=Computer-assisted versus oral-and-written family history taking for identifying people with elevated risk of type 2 diabetes mellitus |title=Cochrane Database of Systematic Reviews |issue=12 |pages=CD008489 |year=2011 |last1=Pappas |first1=Yannis |last2=Wei |first2=Igor |last3=Car |first3=Josip |last4=Majeed |first4=Azeem |last5=Sheikh |first5=Aziz |editor1-last=Car |editor1-first=Josip|hdl=10547/296945 }}</ref> In 2021, a substudy<ref>{{cite journal |last1=Brandberg |first1=H |last2=Sundberg |first2=CJ |last3=Spaak |first3=J |last4=Koch |first4=S |last5=Zakim |first5=D |last6=Kahan |first6=T |title=Use of Self-Reported Computerized Medical History Taking for Acute Chest Pain in the Emergency Department - the Clinical Expert Operating System Chest Pain Danderyd Study (CLEOS-CPDS): Prospective Cohort Study. |journal=Journal of Medical Internet Research |date=27 April 2021 |volume=23 |issue=4 |pages=e25493 |doi=10.2196/25493|pmc=8114166 |pmid=33904821|doi-access=free }}</ref> of a large prospective cohort trial<ref>{{cite journal |last1=Brandberg |first1=H |last2=Kahan |first2=T |last3=Spaak |first3=J |last4=Sundberg |first4=K |last5=Koch |first5=S |last6=Adeli |first6=A |last7=Sundberg |first7=CJ |last8=Zakim |first8=D |title=A prospective cohort study of self-reported computerised medical history taking for acute chest pain: protocol of the CLEOS-Chest Pain Danderyd Study (CLEOS-CPDS). |journal=BMJ Open |date=21 January 2020 |volume=10 |issue=1 |pages=e031871 |doi=10.1136/bmjopen-2019-031871 |pmid=31969363|pmc=7044839 |doi-access=free }}</ref> showed that a majority (70%) of patients with acute chest pain could, with computerized history taking, provide sufficient data  for risk stratification with a well-established risk score ([[Chest pain|HEART score]]).
'''Disadvantages:'''
* Lacks the ability to detect non-verbal cues that may provide critical clinical insights.
* Some patients may feel less comfortable discussing personal health concerns with a computer.
* Studies show that some individuals (14%) find computerized history-taking uncomfortable in sensitive areas like [[sexual history]].


== See also ==
== See Also ==
* [[Genogram]]
* [[Genogram]]
* [[Medical record]]
* [[Medical record]]
* [[Medicine]]
* [[Medicine]]
* [[Physical examination]]
* [[Physical examination]]
* [[Psychoanalysis]] (Freud uses the term ''anamnesis'' to describe neurotics' recounting of their symptoms)
* [[Psychoanalysis]] (Freud's use of ''anamnesis'' in exploring past experiences)


== References ==
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{{Medical records}}
{{Medical records}} {{stub}}
{{Authority control}}


[[Category:Practice of medicine]]
[[Category:Practice of medicine]]
[[Category:Medical terminology]]
[[Category:Medical terminology]]
[[Category:Athletic training]]
[[Category:Athletic training]]
[[Category:History of science by discipline]]
[[Category:History of science by discipline]]

Latest revision as of 22:38, 19 March 2025

Patient information gathered by a physician


The medical history, case history, or anamnesis (from Greek: ἀνά, aná, "open", and μνήσις, mnesis, "memory") refers to the information collected by a physician from a patient during a medical interview. It serves as a fundamental component in assessing the patient's condition, guiding medical diagnosis, and formulating appropriate medical treatments.

Medical history is typically obtained through direct questioning of the patient, and when necessary, from close relatives or caregivers to ensure reliable and objective information. The patient's self-reported issues are classified as symptoms, while findings discovered through direct examination by medical professionals are referred to as clinical signs.

The depth and focus of a medical history vary depending on the context. For example:

A comprehensive history, combined with a physical examination, helps healthcare providers establish a diagnosis and develop an appropriate treatment plan. If a conclusive diagnosis is not immediately possible, a provisional diagnosis is formulated, and further diagnostic testing may be ordered to narrow down potential conditions (the differential diagnosis).

History and Physical (H&P)[edit]

The history and physical (H&P) is the standard method by which physicians collect and organize patient information to support clinical decision-making. The history involves structured questioning, while the physical examination focuses on relevant clinical findings.

A typical medical history follows a standardized structure:

  1. Chief complaint (CC): The primary reason for the patient’s visit.
  2. History of present illness (HPI): A detailed exploration of the current complaint.
  3. Past medical history (PMH): Previous illnesses, hospitalizations, and ongoing medical conditions.
  4. Past surgical history (PSH): Record of previous surgeries and operations.
  5. Family history (FH): Genetic and hereditary conditions relevant to the patient's health.
  6. Social history (SH): Lifestyle factors such as occupation, living arrangements, smoking, alcohol use, and recreational drug use.
  7. Medication history: Current and past medications, including over-the-counter drugs and alternative medicine.
  8. Allergies: Drug, food, and environmental allergies.
  9. Review of systems (ROS): A systematic assessment of symptoms affecting different organ systems.

Following the history, a focused physical examination is conducted to assess the chief concern. Based on these findings, physicians may order additional laboratory tests or medical imaging to confirm a diagnosis and determine appropriate treatment.

Process[edit]

File:Hx in PEDz.pdf

A practitioner typically gathers the following key details:

  • Identification and demographics: Name, age, sex, height, weight.
  • Chief complaint (CC): The primary medical issue and its duration (e.g., chest pain for four hours).
  • History of present illness (HPI): Detailed description of symptoms, their onset, and progression.
  • Past medical history (PMH): Previous illnesses, surgeries, chronic conditions (e.g., diabetes mellitus, hypertension).
  • Review of systems (ROS): Systematic questioning of different organ systems to uncover additional symptoms.
  • Family history (FH): Inherited conditions and illnesses affecting close relatives.
  • Childhood diseases: Particularly relevant in pediatrics.
  • Social history (SH): Living situation, occupation, marital status, lifestyle habits, recreational drug use, exposure to infectious diseases, etc.
  • Medication history: Current and past prescription and non-prescription medications.
  • Allergy history: Known allergies to medications, foods, or environmental triggers.
  • Sexual and gynecological history: If relevant, details about reproductive health, past pregnancies, and sexually transmitted infections.
  • Conclusion and follow-up: Establishing a treatment plan, scheduling further testing, or recommending specialist consultation.

Medical history can be collected using different approaches:

  • Comprehensive history-taking: A detailed and standardized interview, often conducted by medical students, physician assistants, or nurse practitioners.
  • Hypothesis-driven history-taking: A more targeted approach, used by experienced clinicians to rule in or out likely diagnoses efficiently.
  • Computerized history-taking: Increasingly integrated into electronic health records, this method allows for structured and standardized patient data collection.

Review of Systems (ROS)[edit]

A review of systems (ROS) systematically checks for symptoms in various organ systems, ensuring that no significant medical issues are overlooked. It often includes:

Inhibiting Factors[edit]

Several factors may impede effective history-taking:

  • Physical barriers: Unconsciousness, communication disorders, or cognitive impairment.
  • Psychosocial barriers: Language barriers, anxiety, stress, or reluctance to disclose sensitive health information.
  • Lack of continuity in care: Changing physicians may lead to fragmented patient histories.
  • Cultural and personal sensitivities: Patients may hesitate to discuss sexual health, mental health, or substance use.

When patients cannot provide their own history, physicians may rely on collateral history (heteroanamnesis) from family members or caregivers.

Computer-Assisted History Taking[edit]

Computer-assisted history taking systems have been developed since the 1960s to enhance efficiency and accuracy. These systems allow patients to enter medical information electronically before their appointment.

Advantages:

  • Reduces social desirability bias, leading to more honest reporting of lifestyle habits.
  • Integrates seamlessly with electronic medical records for easy access.
  • Saves time and reduces paperwork.

Disadvantages:

  • Lacks the ability to detect non-verbal cues that may provide critical clinical insights.
  • Some patients may feel less comfortable discussing personal health concerns with a computer.
  • Studies show that some individuals (14%) find computerized history-taking uncomfortable in sensitive areas like sexual history.

See Also[edit]




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