Why SAMPLE History Matters
If you work in healthcare, you know that time is often not on your side. Whether you are in an emergency room, an ambulance, or a clinic, you need to get important information fast. But you also need to get the right information. You cannot afford to miss details that might save a life. This is where SAMPLE history comes in. SAMPLE is a memory tool. It helps you ask the most important questions in a logical order. It works for almost any patient, from a child with a fever to an older adult with chest pain. It is simple. It is quick. And it works.
In this blog, we will break down every part of SAMPLE history. We will explain why each part matters. We will give you examples of what to ask. We will also talk about common mistakes and how to avoid them. By the end, you will feel more confident taking patient histories. Let us begin.
What Is SAMPLE History?
SAMPLE history is a standard tool used by healthcare providers. It is often taught in basic life support and advanced life support courses. But it is not just for emergencies. You can use it in any healthcare setting.
The word SAMPLE is an acronym. Each letter stands for a category of information you need to gather:
S – Signs and Symptoms
A – Allergies
M – Medications
P – Past medical history
L – Last oral intake
E – Events leading to the illness or injury
When you ask questions in this order, you build a clear picture of what is happening with your patient. You also avoid skipping important topics. In a busy shift, this structure is your friend.
The Big Picture: How SAMPLE Fits Into Patient Assessment
Before we dive into each letter, let us talk about where SAMPLE fits in your overall assessment.
SAMPLE history is part of the subjective assessment. That means you are asking the patient or family members for information. You are not measuring things yet. You are listening and recording.
In emergency medicine, SAMPLE usually comes after you have checked the ABCs (airway, breathing, circulation). You want to make sure the patient is stable first. Then you take your history.
In primary care, you might use SAMPLE at the start of the visit. It helps you organize your thoughts before you do a physical exam.
Either way, SAMPLE helps you connect the dots. It turns a confused story into usable medical facts.
S Is for Signs and Symptoms: What the Patient Is Feeling and Seeing
This is where you start. You need to know why the patient came to see you today.
First, understand the difference between a sign and a symptom. A symptom is something the patient feels and tells you about. Pain is a symptom. Nausea is a symptom. Dizziness is a symptom. You cannot see these things. You have to ask.
A sign is something you can see or measure. A rash is a sign. Swelling is a sign. High blood pressure is a sign. You can observe these yourself.
When you ask about signs and symptoms, you want to be specific. Use the OPQRST method to dig deeper:
O – Onset: When did it start? What were you doing when it started? Did it come on suddenly or slowly?
P – Provocation/Palliation: What makes it worse? What makes it better? Does moving make it hurt more? Does resting help?
Q – Quality: What does it feel like? Is it sharp? Dull? Burning? Crushing? Stabbing?
R – Radiation: Does the pain move anywhere? Does it go to your arm, jaw, or back?
S – Severity: On a scale of 0 to 10, how bad is it? Is it the worst pain you have ever felt?
T – Time: How long has this been going on? Is it constant, or does it come and go?
Let us look at an example. A patient says, “My chest hurts.” That is not enough information. You need to ask: “When did the pain start? Does it get worse when you walk? Is it sharp or pressure-like? Does it go to your arm? Rate it from 0 to 10. Has it changed since it started?”
Now you have useful data. You can start thinking about heart attack, angina, or something else.
Do not rush this part. Patients are not always good at describing what they feel. They might say “I just feel off” or “I don’t know, it just hurts.” Be patient. Ask follow-up questions. Sometimes the most important clue comes after the third or fourth question.
A Is for Allergies: What the Patient Cannot Have
Allergies can kill patients. You must ask about them every single time. Even if the patient has been here before. Even if their chart says “no known allergies.” You ask again.
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Start with medication allergies. Ask: “Are you allergic to any medications?” If they say yes, write down the name of the drug and what happens when they take it. This is very important. Some patients say they are allergic to penicillin, but when you ask what happens, they say “I got an upset stomach.” That is a side effect, not a true allergy. A true allergy causes hives, swelling, trouble breathing, or anaphylaxis. You still need to note it, but you need to know the difference.
Next, ask about food allergies. Some food allergies can cause serious reactions. Others are mild. Write down what you learn.
Also ask about environmental allergies. Pollen, dust, latex, bee stings. This matters. If you work in a hospital, latex allergy is a big deal. You need to use latex-free gloves.
Finally, ask: “Have you ever had a serious allergic reaction? Have you ever been treated in an emergency room for an allergy? Do you carry an EpiPen?”
If the patient has a known severe allergy, make sure it is clearly documented. Put an allergy band on their wrist if you are in a hospital setting. Tell the rest of the team. This is not a detail you forget.
M Is for Medications: What the Patient Takes
You need a complete list of medications. Not just prescriptions. Over-the-counter drugs, vitamins, herbal supplements, and birth control all count.
Start by asking: “What medications do you take?” If the patient has their pill bottles, ask to see them. This is the best way to get accurate information. Patients often forget drug names or dosages. They might say “my little blue pill” or “the water pill.” Pill bottles remove the guesswork.
Write down the name, dose, and how often they take it. For example: Lisinopril 10 mg once daily. Metformin 500 mg twice daily.
You also want to know about compliance. Ask: “Do you take your medications every day? When was the last time you missed a dose?” Some patients skip doses because of cost. Some forget. Some stop taking meds because they feel better. This information changes how you interpret their symptoms.
Ask about recent changes too. “Has any medication been added or stopped in the last two weeks? Has your dose changed?” A new medication could be causing side effects. A stopped medication could be causing withdrawal or a return of symptoms.
Do not forget about over-the-counter drugs. Aspirin, ibuprofen, antacids, allergy pills. These matter. Herbal supplements like St. John’s wort, ginseng, or echinacea can interact with prescription drugs. Always ask.
P Is for Past Medical History: What the Patient Has Been Through
Past medical history gives you context. You cannot understand what is happening now if you do not know what happened before.
Start with medical conditions. Ask: “Do you have any ongoing medical problems? High blood pressure? Diabetes? Heart disease? Asthma? Seizures? Cancer?” Let the patient answer. Then ask specifically about common conditions they might forget to mention, like high cholesterol or depression.
Next, ask about surgeries. “Have you ever had surgery? When? What kind?” If the patient had a hysterectomy 20 years ago, that might not matter today. If they had heart bypass surgery six months ago, that matters a lot.
Ask about injuries. “Have you ever had a serious injury? Broken bones? Head trauma?” Past injuries can cause chronic pain or limit mobility.
Ask about pregnancies. For female patients, ask: “Have you ever been pregnant? How many times? Any complications?” This is relevant for many conditions, including blood clots and back pain.
Ask about immunizations. “Are you up to date on your vaccines? Have you had your flu shot this year? Pneumonia vaccine? Tetanus?” This is especially important for older adults and patients with chronic illness.
Finally, ask about childhood illnesses. For older patients, ask: “Did you have measles, mumps, or chickenpox as a child?” Many adults do not know if they had these diseases, but it is worth asking.
Past medical history helps you see patterns. A patient with diabetes and high blood pressure who now has chest pain is high risk for a heart attack. A patient with asthma who now has shortness of breath might be having an asthma attack. The past informs the present.
L Is for Last Oral Intake: What and When the Patient Last Ate or Drank
This question seems simple, but it has serious implications. You need to know when the patient last had anything by mouth.
Start with: “When did you last eat or drink anything?” Get a specific time. “About 4 PM” is okay. “This morning” is not specific enough. “I don’t remember” is not acceptable. Ask if they can think harder or if a family member knows.
Then ask: “What did you have?” This matters too. A full meal is different from a few sips of water. Heavy, greasy food is different from clear liquids.
Why does this matter? There are several reasons.
First, surgery and procedures. If the patient might need surgery, anesthesia requires an empty stomach. Full stomachs increase the risk of vomiting and aspiration. You need to know exactly when they last ate.
Second, diabetes. A diabetic patient who has not eaten in 12 hours and now feels dizzy and sweaty probably has low blood sugar. You treat that immediately.
Third, nausea and vomiting. If the patient cannot keep food down, they are at risk for dehydration. You need to know how long this has been going on.
Fourth, poisoning or overdose. What the patient ingested and when tells you how to treat them. Activated charcoal only works if given soon after ingestion.
Do not skip this question. It is not just small talk. It is medical data.
E Is for Events: What Happened Right Before This
The final letter helps you understand the circumstances. You need to know what was happening when the illness or injury began.
Ask: “What were you doing right before this started?” The answer can be very revealing.
For an injury: “I was walking down the stairs and I slipped.” Or “I was playing basketball and I twisted my ankle.” Or “I was in a car accident.” This tells you about mechanism of injury. A fall from standing is different from a fall from a ladder. A car accident at 20 miles per hour is different from one at 70 miles per hour.
For an illness: “I was watching TV and suddenly felt this crushing chest pain.” Or “I ate lunch and then my stomach started hurting.” Or “I was at work and felt dizzy and had to sit down.” This tells you about onset and possible triggers.
You also want to ask about other events. “Has anything like this happened before?” “Have you been under a lot of stress lately?” “Have you traveled recently?” “Have you been around anyone who was sick?” “Have you had any recent injuries, falls, or accidents?” “Have you had any recent procedures at the dentist or doctor?”
Do not forget to ask about the environment. “Were you in a hot environment? Cold? Did you use any chemicals or cleaners?” These details matter.
Also ask: “What have you done since this started?” Did they take any medication? Did they try to treat it themselves? Did they call their doctor? Did they wait a long time before coming in? This tells you about the severity and their health behaviors.
The events section ties everything together. It is the story behind the symptoms.
Putting It All Together: How to Conduct a SAMPLE History Smoothly
Now you know what to ask. But how do you actually do it in real life? It can feel awkward at first. Here are some tips to make it flow better.
Start with open-ended questions. Begin with: “So tell me what happened today.” Let the patient talk. They will often give you a lot of the SAMPLE information without you asking each question separately.
Listen actively. Nod. Make eye contact. Say “Okay” or “I see.” This encourages the patient to keep talking.
Fill in the gaps. When the patient pauses, look at your mental checklist. Did they cover signs and symptoms? Did they mention medications? If not, ask specifically. “You mentioned you take blood pressure medicine. What is the name of that?”
Use plain language. Do not say “What is your past medical history?” Say “Do you have any health problems like diabetes or high blood pressure?” Patients understand this better.
Be patient with silence. Some patients need time to think. Do not rush them. Wait a few seconds. They may remember something important.
Involve family members. If the patient is confused, too sick, or too young to answer, ask family or caregivers. They often know the medications, allergies, and events.
Write it down. Do not rely on memory. Chart as you go or immediately after. You will forget details in a busy shift.
Verify and clarify. If something does not make sense, ask again. “You said you take insulin, but you do not have diabetes. Can you tell me more about that?” There may be a misunderstanding.
Common Mistakes and How to Avoid Them
Even experienced providers make mistakes with SAMPLE history. Here are the most common ones and how to avoid them.
Mistake 1: Asking questions out of order. It is easy to jump around. You might ask about medications, then allergies, then symptoms. This confuses the patient and you may miss something. Stick to the order. It works.
Mistake 2: Not asking about over-the-counter drugs. Patients do not always think of ibuprofen or vitamins as “medications.” You have to ask specifically. “Do you take any Tylenol, Advil, or Aleve? What about vitamins or herbal supplements?”
Mistake 3: Accepting vague answers. “I’m allergic to some antibiotics.” Which ones? “I don’t remember.” This is not acceptable. Ask the patient to check at home and call you. Check old records. Ask the pharmacy. Do not leave it blank.
Mistake 4: Forgetting to ask about last oral intake in non-surgery patients. You think: “This patient is not having surgery, so I don’t need to ask.” But what if the patient has diabetes? What if they are vomiting? What if they need a procedure later? Always ask.
Mistake 5: Not documenting events thoroughly. “MVA” (motor vehicle accident) is not enough. What kind of accident? Speed? Damage? Airbags? Position in vehicle? Seatbelt use? Loss of consciousness? The more details, the better.
Mistake 6: Assuming the patient knows their history. Many patients do not know their own medical information. They may not know the names of their medications. They may not know what surgeries they had. They may not know why they take certain pills. Do not get frustrated. This is common. Use other resources like family, old records, and pharmacies.
Special Populations: Adapting SAMPLE for Different Patients
SAMPLE history is flexible. You can adapt it for different patient groups.
Pediatric patients. If the child is old enough, ask them questions directly. But parents are your main source of information. Ask about birth history, developmental milestones, and immunization status. For infants, ask about feeding, wet diapers, and activity level.
Elderly patients. Older adults often have multiple medical problems and take many medications. Allow extra time. They may have hearing or memory problems. Speak clearly and face them. Ask about falls, memory changes, and functional status. Can they bathe, dress, and cook for themselves?
Patients with communication barriers. If the patient does not speak your language, use a professional interpreter. Family members can help, but they may not be neutral. If the patient is deaf or hard of hearing, use writing or sign language. If the patient has cognitive impairment, keep questions simple and use family input.
Mental health patients. SAMPLE still applies. Ask about symptoms, medications, and past psychiatric history. Be calm and nonjudgmental. Do not dismiss physical complaints as “just psychiatric.” These patients get physically ill too.
Unresponsive patients. You cannot ask questions. Look for medical alert jewelry. Check the wallet for identification and medication lists. Ask family, bystanders, or first responders. Look at the environment. Are there pill bottles? Empty alcohol bottles? Drug paraphernalia? Notes? Every clue helps.
Documentation: Writing Your SAMPLE History
Good documentation protects the patient and protects you. Here is how to write a SAMPLE history note.
Be clear and concise. Use short sentences. Do not use abbreviations that others may not understand.
Be specific. Instead of “Patient has chest pain,” write “Patient reports substernal chest pressure radiating to left arm, started 2 hours ago while resting, rated 7/10, worse with movement, better with sitting still.”
Use quotes when helpful. “Patient states: ‘It feels like an elephant is sitting on my chest.'” This paints a vivid picture.
Include negatives. Document what the patient denied. “Denies shortness of breath, nausea, vomiting.” This shows you asked.
Organize by category. You can write:
S: Chest pain, as above. No other symptoms.
A: No known drug allergies.
M: Lisinopril 10 mg daily. Ibuprofen as needed.
P: Hypertension. No surgeries.
L: Last ate breakfast at 0800.
E: Watching TV when pain started. No recent stress or illness.
Sign and date every note. This is non-negotiable.
Beyond SAMPLE: What Comes Next
SAMPLE history is not the end of your assessment. It is the beginning.
After you have your SAMPLE history, you move to the physical exam. You check vital signs. You listen to the heart and lungs. You palpate the abdomen. You look at the injured area.
Then you consider diagnostics. Do you need an EKG? Blood work? X-rays? CT scan? Your SAMPLE history guides these decisions.
Then you develop a treatment plan. Based on what the patient told you and what you found on exam, what do you do next? Admit? Discharge? Prescribe? Refer?
Finally, you reassess. Did your treatment help? Did the patient get better or worse? Is there new information? Medicine is not static. You constantly update your assessment.
SAMPLE is your foundation. Build on it.
Conclusion:
SAMPLE history is simple. That is its strength. You do not need complex tools or advanced training. You just need to ask the right questions in the right order. But simple does not mean easy. It takes practice. You will forget questions sometimes. You will get interrupted. You will have difficult patients. That is okay. Keep practicing.
Remember: Signs and symptoms tell us what is wrong. Allergies tell us what to avoid. Medications tell us what the body is receiving. Past history tells us what the body has been through. Last intake tells us about metabolic status. Events tell us the story.
When you master SAMPLE, you become a better clinician. You miss fewer things. You communicate better with your team. You provide safer care. So next time you walk into a patient room, take a breath. Remember your acronym. Start with S. End with E. And listen. Your patients are telling you what is wrong. SAMPLE helps you hear them.
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Dr. Connor Yost is an Internal Medicine resident at Creighton University School of Medicine in Arizona and an emerging leader in clinical innovation. He currently serves as Chief Medical Officer at Skriber, where he helps shape AI-powered tools that streamline clinical documentation and support physicians in delivering higher-quality care. Dr. Yost also works as a Strategic Advisor at Doc2Doc, lending his expertise to initiatives that improve financial wellness for physicians and trainees.
His professional interests include medical education, workflow redesign, and the responsible use of AI in healthcare. Dr. Yost is committed to building systems that allow clinicians to spend more time with patients and less on administrative tasks. Outside of medicine, he enjoys photography, entrepreneurship, and family life.
