Surgeries: note the type of procedure, date, hospital, surgeon, and any complications.
Current medications: note name, dosage, frequency of any medication, including any over-the-counter medications and herbal remedies. Note whether patient is taking the medications according to the prescribed instructions.
Allergies: note any environmental, food, or drug allergies, as well as the specific type of reaction, e.g. anaphylaxis, rash, itching.
Diet: ask about everything the patient has eaten the day before and for the past week. Note the type of food consumed and do a nutritional status assessment. Medically, however, this is considered to be a part of social history. Dietary supplements would also be under PMH.
Sleep: a useful mnemonic for sleep patterns is BEARS, for Bedtime problems (e.g. snoring, sleep apnea, or nightmares), Excessive daytime sleepiness, Awakenings at night, Regularity and duration of sleep, Snoring.[2]
Birth history: details of labor and delivery of patient, admission to NICU, maternal fever, duration of rupture of membranes, Apgar scores (particularly import in first three months of life)
Growth and development: plots of height, weight, and head circumference are standard content for pediatric records, any change in trajectory (e.g. growth plots which cross percentile lines rather than running parallel), developmental mile stones, any IQ or other developmental testing
The Centers for Medicare and Medicaid Services[5] has published criteria for what constitutes a reimbursable PMH. A PMH is considered one of three elements of the "Past, Family, and Social History" (abbreviated as PFSH):[6]
Past medical history: "the patient's past experiences with illnesses, operations, injuries and treatments";
Family history: "a review of medical events in the patient's family, including diseases which may be hereditary or place the patient at risk";
Social history: "an age-appropriate review of past and current activities".
A pertinent PFSH consists of at least one of the three components; a full PFSH consists of two or three components for an established patient, or all three components for a new patient visit.[6]