SAMPLE History Taking

SAMPLE

The SAMPLE History Medical history obtained from the patient, family and bystanders

Signs and Symptoms Signs: what you can observe and measure about the patient, such as the vital signs. Symptoms: what the patient describes to you- pain, numbness...etc. You cannot observe these, so you must ask

Allergies: "Do you have any allergies?" This includes medication, food, or other environmental factors. Check for medical alert tags.

Medications: "Are you on any medications? Have you taken medications recently?" This includes prescriptions, over-the-counter, birth control pills, illicit drugs (be tactful, indicate that you are an EMT, not a police officer, and you need the information for treatment purposes), or herbal medicine. Look for medical tags.

Pertinent past history: "Have you ever had any illnesses? Operations? Have you ever been admitted to a hospital?" Find out medical problems and past surgical procedures that may have a bearing on the chief complaint.

Last oral intake: "When did you last eat or drink something? What was it?" A diabetic patient who hasn't consumed anything for 8 hours may be hypoglycemic.

Events leading up to the injury or illness: "What happened? How did this happen?" The events leading up to the injury provide clues for the underlying cause.

Document all pertinent findings from the SAMPLE history on the PCR (Prehospital care report)

Additional Resources

• SAMPLE can be expanded with follow-up questions. An example of this can be seen here. This file was created using SAMPLE building blocks and expanding on them to create a run sheet that can be handed to another provider during transfer of care or assist a less experienced provider in asking pertinent follow-up questions.
• Additional follow up questions may be found here.