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Medical History and Physical Exam: What to Expect and Why It Matters

Why your medical history matters

Your story is often the most important part of your visit. A careful history helps your clinician understand your symptoms, spot risk factors, and decide what testing or treatment makes sense. It also prevents duplicate tests and unsafe drug interactions.

Your medical history usually includes current concerns, past conditions, surgeries, hospital stays, allergies and reactions, medicines and supplements, family history, immunizations, mental health, and lifestyle factors such as sleep, diet, activity, tobacco, alcohol, and other substances. Your clinician may also ask about social needs that affect health such as transportation, housing, or caregiving support. Explore social support options at https://understoodcare.com/care-types/social-support

What to expect during the history

Core questions you may hear

  • What brings you in today, and when did it start
  • Where the symptoms are, how they feel, what makes them better or worse, and how they affect your day
  • Past medical problems, procedures, or hospital stays
  • All medicines and supplements you take, including dose and timing
  • Allergies and what reactions you had
  • Family history of conditions such as heart disease, stroke, diabetes, cancer, or dementia
  • Immunizations and infectious disease exposures or recent travel
  • Mood, stress, and sleep
  • Work and home environment, physical activity, and nutrition
  • Sexual and reproductive health as relevant
  • Tobacco, alcohol, and other substances
  • Safety at home and fall risk
  • Functional abilities such as walking, dressing, or managing medicines
  • Advance care planning if you want to discuss it

Tips for sharing your history

Bring a written list of medicines with doses and timing. Include over the counter products and supplements. If you monitor blood pressure, glucose, or oxygen at home, bring recent readings. Jot down questions beforehand and note any specific goals for the visit.

Talk to an Advocate (646) 904-4027
Talk to an Advocate (646) 904-4027

What to expect during the physical exam

The exam checks overall wellbeing and looks for findings that support or rule out possible causes of your symptoms. Your clinician will explain what each part is for and can answer questions as you go.

Vital signs and basic measurements

Most visits include blood pressure, heart rate, breathing rate, temperature, and oxygen level. Height, weight, and a body mass index estimate are often measured to help assess nutrition and risk.

A head to toe look

The exam is tailored to your needs and may include

  • General appearance and how you move and speak
  • Skin, hair, and nails
  • Eyes, ears, nose, mouth, and throat
  • Neck and thyroid
  • Heart and pulses
  • Lungs and breathing sounds
  • Abdomen and digestive organs
  • Muscles, joints, and spine
  • Nerves, reflexes, strength, and sensation
  • Feet, especially if you have diabetes or circulation concerns

Sensitive exams

Breast, pelvic, genital, rectal, or prostate exams are done when medically appropriate. You can ask for a chaperone. You can ask questions, request a pause, or decline parts that you are not comfortable with, while discussing risks and benefits.

How history and exam guide testing and prevention

History and exam findings help decide if tests are needed right now, later, or not at all. They also guide age and risk based screening such as blood pressure, certain cancers, and depression. Many expert groups encourage choosing tests that are supported by evidence, not duplicated, and free from unnecessary risk. A focused plan saves time, reduces cost, and avoids false alarms. If you need help lowering medication costs, see https://understoodcare.com/care-types/lower-costs-of-medication

A healthcare expert on your side.
A healthcare expert on your side.

How to prepare as a patient

  • Bring your medicine list or all pill bottles in a bag
  • Bring recent home readings or symptom notes
  • Know key family history, such as close relatives with early heart disease, stroke, or cancer
  • Bring photo identification and insurance card if you have one
  • Bring copies of recent test results or imaging if done elsewhere
  • Ask for an interpreter if you prefer another language or use sign language
  • Ask for accommodations if you need help with hearing, vision, mobility, or understanding information
  • Write down your top questions and what a good outcome looks like for you

What happens after the visit

You should leave with an assessment and plan that explains what your clinician thinks is going on, what to watch for, and clear next steps. Plans often include education, medicines or changes to current medicines, referrals, labs or imaging if needed, and follow up timing. Patient portals can help you see test results, read visit notes, request refills, send messages, and keep track of appointments. Ask how your clinic shares results and when to call if something changes.

Special situations

Telehealth visits

Virtual visits work well for many concerns such as follow ups, medicine refills, mental health, sleep issues, and some chronic conditions. They are not ideal when the problem requires a hands on exam such as abdominal pain that needs pressing on the belly or a new neurologic symptom that needs a full exam. Your clinician can help decide when in person care is best.

Medicare wellness visits

A Medicare wellness visit focuses on prevention and care planning. It may include a review of your history and risks, vaccines, screening schedules, and safety and social needs. It is different from a problem focused visit and does not always include a full physical exam.

Red flags to mention right away

Call emergency services for chest pain, severe shortness of breath, signs of stroke such as sudden face droop, arm weakness, or trouble speaking, a severe new headache, fainting, heavy bleeding, or thoughts of harming yourself or others.

Frequently asked questions

How long will it take
A first visit for a complex concern may take longer. A simple follow up may be brief. Ask the office when you schedule.

Can I decline parts of the exam
Yes. You can ask to stop or skip parts. Your clinician will explain the risks and benefits and note your preferences.

Will everything be documented
Yes. Your history, exam findings, assessment, and plan are part of your record. You have a right to see your records and to request corrections.

Do I have to answer personal questions
You can always ask why a question is relevant. Sharing information about medicines, allergies, safety, mental health, sexual health, and substance use helps your clinician keep you safe and tailor care.

Can I bring someone with me
Yes. A support person can help with details and take notes if you want.

Advocates are free because insurance covers them
Advocates are free because insurance covers them
  • Your story guides care as much as the exam
  • A clear medicine list and symptom notes make your visit safer and smoother
  • Sensitive exams are explained and consented and you can ask for a chaperone
  • Testing should be targeted by history and exam and by evidence based screening guidance
  • Use your portal and ask questions so your plan is clear

References and Related Resources

This content is for education only and does not replace professional medical advice. If you have new weakness, severe pain, fever with confusion, chest pain, or trouble breathing, call emergency services.

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