π Key Information Summary
- History accounts for approximately 60β80% of diagnostic information; a structured, systematic approach is the single most valuable clinical skill a practitioner can develop.
- Establish rapport before clinical questioning: introduce yourself, confirm the patient's preferred name and pronouns, explain the purpose and estimated duration of the consultation, and ensure privacy.
- Use the presenting symptom as the scaffold β elicit the chief complaint in the patient's own words, then expand using SOCRATES (Site, Onset, Character, Radiation, Alleviating/Associated factors, Timing, Exacerbating factors, Severity).
- Open questions first, closed questions second: begin with broad, non-directive prompts ("Tell me what brought you in today") before narrowing with specific closed questions to refine the differential.
- Past medical, surgical, medication, and allergy history must be documented systematically; always ask about complementary/alternative medicines and non-prescribed substances.
- Social history is clinical history: smoking (pack-years), alcohol (AUDIT-C), recreational drug use, occupation, housing, driving, domestic safety, and social supports directly influence diagnosis, management, and discharge planning.
- Family history should include first-degree relatives with attention to hereditary conditions (familial hypercholesterolaemia, hereditary cancer syndromes, cardiomyopathies, type 2 diabetes).
- Systems review (review of systems) is a structured head-to-toe screen that identifies unreported symptoms and prevents anchoring bias β cover cardiovascular, respiratory, gastrointestinal, genitourinary, haematological, neurological, endocrine, and musculoskeletal domains.
- Adapt communication for Aboriginal and Torres Strait Islander patients: use plain language, allow silence, involve family or an Aboriginal Health Worker/practitioner where preferred, and be aware of culturally sensitive topics such as "sorry business" and gender-specific health issues.
- Paediatric and geriatric histories require modification: collateral from carers/parents, developmental milestones in children, and cognitive screening in older adults are essential adjuncts.
- Document contemporaneously using structured formats (SOAP, problem-based, or time-based) that comply with RACGP and NSQHS record-keeping standards.
- Safety-netting is part of the history: clarify red-flag symptoms, agree on follow-up arrangements, and provide written information before the patient leaves.
Introduction & Australian Context
History taking is the foundation of clinical reasoning. In Australian general practice, the average consultation length is approximately 15β18 minutes under the Medicare Benefits Schedule (MBS) Level B/C consult items, during which the clinician must establish rapport, elicit the presenting complaint, explore relevant background, and safety-net β all while maintaining an accurate medicolegal record.
Hampton et al. (1975) demonstrated that up to 82% of diagnoses could be made from the history alone, a finding repeatedly confirmed in contemporary Australian and international studies. Despite advances in point-of-care testing and imaging, the clinical history remains the most cost-effective and diagnostically powerful tool available to the practitioner.
The RACGP Standards for General Practices (5th edition) mandates structured clinical records, culturally safe consultations, and patient-centred communication as core accreditation requirements. This article outlines the general principles of a comprehensive medical history, with specific adaptations for the Australian healthcare context.
Bedside Manner & Establishing Rapport
The quality of the therapeutic relationship established in the first 60 seconds of a consultation determines the completeness and reliability of the history obtained. Patient-centred communication, as described by the Calgary-Cambridge model, is the accepted framework in Australian medical education.
Pre-Consultation Preparation
- Review the patient's My Health Record, existing clinical notes, recent investigations, and correspondence before the patient enters the room.
- Note any outstanding recalls, screening due dates (cervical screening, bowel screening, Aboriginal and Torres Strait Islander health checks β MBS Item 715), and chronic disease management plans (GPMP β MBS Item 721, TCA β MBS Item 723).
- Check for alerts: anaphylaxis, complex care needs, advance care directives, or culturally specific communication requirements.
The Opening
1
Introduce & Greet
State your name and role. Ask the patient how they wish to be addressed. Use a warm, unhurried greeting β standing to greet the patient is associated with higher patient satisfaction scores.
2
Confirm Identity
Verify full name and date of birth. In hospital settings, use three-point identification (name, DOB, MRN) per NSQHS Standard 5 (Comprehensive Care).
3
Establish Privacy & Consent
Ensure the consultation room is private. If a chaperone, interpreter (preferably a professional interpreter rather than family, especially for sensitive topics), or Aboriginal Health Worker is required, arrange this before commencing.
4
Set the Agenda
Use an opening question such as: "What would you like to cover today?" This acknowledges patient autonomy and prevents the "doorknob complaint" at the end of the consultation.
Communication Techniques
| Technique | Description | Example |
|---|---|---|
| Open questions | Non-directive; allow the patient to narrate in their own words | "Tell me about the pain." |
| Closed questions | Specific; used to clarify or confirm a hypothesis | "Is the pain sharp or dull?" |
| Facilitation | Encouraging the patient to continue | "Go onβ¦", "And then what happened?" |
| Clarification | Resolving ambiguity | "When you say 'dizzy', do you mean the room is spinning or that you feel faint?" |
| Reflection / Echo | Repeating the patient's words to validate and encourage elaboration | Patient: "I'm just so tired." Clinician: "Tiredβ¦" |
| Empathic acknowledgement | Recognising the patient's emotional state | "That sounds really difficult." |
| Summarising | Restating key points to confirm understanding | "So just to check I have this right β the chest pain started three hours agoβ¦" |
| Signposting | Explaining transitions in the consultation | "I'd now like to ask you some specific questions about your heart and lungs." |
Interpreter use: Under the Australian Charter of Healthcare Rights and the NSQHS Standards, patients with limited English proficiency are entitled to a professional interpreter. Using family members (especially children) as interpreters is clinically unsafe, ethically inappropriate, and should be avoided except in genuine emergencies. The Translating and Interpreting Service (TIS National β 131 450) is available 24/7 at no cost to patients in public health settings.
Presenting Symptom & History of Presenting Illness
The presenting complaint (PC) should be recorded in the patient's own words. The history of presenting illness (HPI) is then expanded using a structured mnemonic β the most widely taught in Australian medical schools is SOCRATES.
SOCRATES Mnemonic
| Letter | Domain | Key Questions |
|---|---|---|
| S β Site | Location of the symptom | "Where exactly is the pain? Can you point to it with one finger?" |
| O β Onset | When and how it started | "When did it first come on? Was the onset sudden or gradual? What were you doing at the time?" |
| C β Character | Nature / quality of the symptom | "Can you describe what it feels like?" (Offer descriptors if needed: sharp, dull, burning, throbbing, crushing, band-like.) |
| R β Radiation | Where the symptom spreads | "Does it travel anywhere else?" (e.g., chest pain radiating to the left arm or jaw in acute coronary syndrome.) |
| A β Alleviating / Associated factors | What makes it better and what else is happening | "Does anything make it better β rest, medication, position?" "Have you noticed any other symptoms at the same time?" |
| T β Timing | Duration, frequency, pattern | "How long does each episode last? How often does it occur? Is it constant or intermittent? Is there a pattern β worse in the morning, after meals?" |
| E β Exacerbating factors | What makes it worse | "Is there anything that brings it on or makes it worse β movement, breathing, eating, stress?" |
| S β Severity | Impact and intensity | "On a scale of 0β10, how bad is it at its worst? Has it changed since it started? How is it affecting your daily life, work, sleep?" |
Expanding the HPI Beyond SOCRATES
SOCRATES is a starting framework. A thorough HPI also includes:
- Previous episodes: "Have you ever had this before? If so, what was the diagnosis?"
- Investigations already performed: "Have you had any tests β blood tests, scans, ECGs?"
- Treatments tried: "Have you taken anything for it? Did it help?" (Include over-the-counter, complementary, and traditional medicines.)
- Patient's ideas, concerns, and expectations (ICE): "What do you think might be causing it? What worries you most? What were you hoping we could do today?"
- Impact on function: Activities of daily living, work, driving (relevant to mandatory reporting obligations in Australia), childcare, and psychosocial wellbeing.
Pro tip: Asking "What else?" or "Is there anything else you'd like to mention?" before moving on from the presenting complaint significantly reduces missed diagnoses and the incidence of late-presenting doorknob complaints (Heritage et al., 2007).
Past History, Social History & Family History
Past Medical History (PMH)
- Record all significant medical conditions, including those currently "inactive" or in remission β previous diagnoses may be the key to the current presentation.
- Ask about hospital admissions and emergency department presentations, particularly if transferring care between facilities.
- Document previous surgical procedures, including year and any complications (e.g., difficult intubation, malignant hyperthermia, adverse reaction to anaesthesia).
- Include relevant screening history: cervical screening (National Cervical Screening Program), bowel screening (National Bowel Cancer Screening Program β faecal immunochemical test sent at age 50), breast screening (BreastScreen Australia β age 50β74), cardiovascular risk assessment (absolute cardiovascular risk β MBS Item 699/177).
Medication History
- Record name (generic preferred), dose, route, frequency, indication, prescriber, and compliance for each medication.
- Include over-the-counter medications (analgesics, antacids, antihistamines), complementary medicines (vitamins, herbal preparations, fish oil, St John's Wort β relevant to drug interactions), and topical agents.
- Always ask about: anticoagulants, insulin/antidiabetics, immunosuppressants, opioids, and contraceptives (including type and last use).
- Verify medication adherence: "How do you remember to take your medications? Are there any you have stopped or are not taking as prescribed?"
Allergy & Adverse Drug Reaction (ADR) History
Critical distinction β allergy vs. intolerance: Always clarify the nature of the reaction. A patient who reports a "penicillin allergy" may have experienced nausea (intolerance, not a true allergy) rather than anaphylaxis. True allergy (IgE-mediated) requires specific management pathways, allergist referral, and documentation. Mislabelling allergies limits future antibiotic options (e.g., withholding flucloxacillin for cellulitis and resorting to inferior alternatives) and is a recognised patient safety issue in Australian hospitals.
- Document: drug/substance, type of reaction (rash, anaphylaxis, GI upset, angioedema), severity, date, and any subsequent tolerance (e.g., "reported penicillin allergy β tolerated amoxicillin in 2019").
- Record environmental allergies (latex, iodine/chlorhexidine β relevant to procedural consent) and food allergies (relevant to contrast reactions and procedural fasting).
Social History
The social history is not a mere formality β it is a critical determinant of diagnosis, management planning, discharge disposition, and medicolegal risk. In Australian practice, the following domains must be assessed:
| Domain | Key Questions | Clinical Relevance |
|---|---|---|
| Tobacco | Current/former/never; quantity (cigarettes/day); duration; pack-years; quit attempts | Cardiovascular risk, cancer screening eligibility, perioperative risk |
| Alcohol | AUDIT-C screening tool; standard drinks/day; binge episodes; history of withdrawal or dependency | Hepatic disease, Wernicke's encephalopathy, medication interactions, fetal alcohol spectrum disorder (FASD) in pregnancy |
| Recreational drugs | Type (cannabis, methamphetamine, opioids, MDMA, inhalants); route; frequency | Infective endocarditis, drug-induced psychosis, hepatitis C risk, QTc prolongation |
| Occupation | Current job; exposure hazards (asbestos, silica, chemicals); physical demands; shift work | Occupational lung disease, workers' compensation, fitness-for-work assessment |
| Living situation | Household composition; housing type; stairs; access to bathroom; homelessness risk | Discharge planning, falls risk, child/elder safety |
| Driving | Holds licence; private or commercial; impairment risk (syncope, seizures, vision, hypoglycaemia) | Mandatory reporting obligations vary by state/territory (e.g., Austroads Assessing Fitness to Drive 2022) |
| Functional status | Mobility aids; activities of daily living (ADLs); informal supports; formal care packages (Home Care Packages, NDIS) | Rehabilitation planning, aged care assessment, NDIS access |
| Psychosocial | Support network; relationship status; recent bereavement; financial stress; domestic and family violence (DFV) screening | Mental health safety planning, social work referral, DFV response |
Family History (FH)
- Ask about first-degree relatives (parents, siblings, children) β age (or age and cause of death) and significant medical conditions.
- Conditions with strong hereditary patterns to specifically screen for: ischaemic heart disease (premature: males <55, females <65), type 2 diabetes mellitus, breast/ovarian/colorectal cancer (BRCA, Lynch syndrome), familial hypercholesterolaemia, hypertrophic cardiomyopathy, long QT syndrome, haemochromatosis, and coeliac disease.
- Consider ethnic-specific screening: e.g., haemoglobinopathies in Southeast Asian and Mediterranean populations; Tay-Sachs in Ashkenazi Jewish families.
- Document consanguinity where relevant β increased autosomal recessive risk.
- Use the family history to calculate absolute cardiovascular risk (Australian CVD Risk Calculator β CVDCalculate) and guide referral for genetic counselling (e.g., via Clinical Genetics Services in each state/territory).
Systems Review (Review of Systems)
The systems review is a structured, head-to-toe screen that identifies symptoms the patient may not have volunteered during the presenting complaint. It serves as a safeguard against anchoring bias β the tendency to fixate on an initial hypothesis and miss alternative diagnoses. In Australian general practice, a standard systems review covers eight domains.
Cardiovascular
- Chest pain or tightness (SOCRATES)
- Palpitations (regular vs irregular; associated syncope)
- Dyspnoea β exertional vs rest; orthopnoea; paroxysmal nocturnal dyspnoea (PND)
- Peripheral oedema (bilateral vs unilateral)
- Syncope or presyncope (exertional syncope is a red flag)
- Claudication (intermittent claudication distance)
Respiratory
- Cough β productive (colour, volume, haemoptysis) vs dry
- Wheeze; stridor
- Dyspnoea (use the mMRC Dyspnoea Scale or MRC Breathlessness Scale)
- Sputum β colour (yellow, green, rust-coloured, blood-streaked), volume, consistency
- Pleuritic chest pain
- Night sweats (think tuberculosis, lymphoma)
Gastrointestinal
- Nausea, vomiting (content, timing, blood/bile)
- Dysphagia (solids vs liquids β progressive dysphagia is sinister until proven otherwise)
- Heartburn, reflux, dyspepsia
- Abdominal pain (SOCRATES)
- Bowel habit β constipation, diarrhoea (acute vs chronic), mucus, blood (bright red vs melaena)
- Weight loss (intentional vs unintentional β unexplained weight loss β₯5% in 6 months warrants investigation)
- Jaundice, pruritus
Genitourinary
- Dysuria, frequency, urgency, haematuria
- Urgency, incontinence (stress vs urge vs overflow)
- Nocturia (number of episodes; exclude benign prostatic hyperplasia, heart failure, diabetes)
- Flank pain / loin pain (renal colic, pyelonephritis)
- Vaginal discharge or bleeding (postmenopausal bleeding is a two-week-wait referral in most Australian jurisdictions)
- Erectile dysfunction (may be the presenting complaint of cardiovascular disease or diabetes)
- STI risk assessment β number of partners, condom use, previous STIs; offer HIV/STI screening per Australian STI Management Guidelines (ASHM)
Haematological
- Fatigue, lethargy (assess for iron deficiency, anaemia, malignancy)
- Easy bruising, petechiae, prolonged bleeding
- Recurrent infections (consider immunodeficiency)
- Lymphadenopathy (site, duration, tenderness)
- Night sweats, unexplained fevers (B symptoms for lymphoma)
Neurological
- Headache (SOCRATES; new vs chronic; thunderclap onset = emergency)
- Dizziness β true vertigo vs presyncope vs disequilibrium vs light-headedness
- Seizures (focal vs generalised; first seizure requires urgent investigation)
- Weakness (distribution; upper vs lower motor neuron pattern)
- Numbness, paraesthesia, tingling (dermatomal vs glove-and-stocking)
- Visual disturbance (diplopia, field loss, blurred vision)
- Speech disturbance (dysarthria vs dysphasia)
- Memory, concentration, cognitive decline (use MMSE or MoCA as adjunct)
Endocrine
- Polyuria, polydipsia, polyphagia (classic triad of diabetes mellitus)
- Heat/cold intolerance
- Tremor, weight change, sweating
- Hair loss, skin changes (vitiligo, acanthosis nigricans)
- Menstrual irregularity, galactorrhoea, hirsutism (pituitary/adrenal/ovarian pathology)
- Symptoms of hypoglycaemia or hyperglycaemia in known diabetics
Musculoskeletal
- Joint pain (which joints; symmetry; inflammatory vs mechanical pattern)
- Morning stiffness duration (β₯30 minutes suggests inflammatory arthritis)
- Swelling, redness, warmth of joints
- Back pain (red flags: age <20 or >55, history of malignancy, unexplained weight loss, fever, IV drug use, failure to improve with conservative management, neurological signs β use the STarT Back screening tool for risk stratification)
- Muscle weakness, myalgia (proximal vs distal)
- Functional limitation: grip strength, stair climbing, rising from a chair
When to expand the systems review: In time-limited consultations (e.g., MBS Level A or urgent presentations), a targeted systems review directly relevant to the presenting complaint is acceptable. In comprehensive health assessments (MBS Item 701, 703, 705, 707, or 715 for Aboriginal and Torres Strait Islander patients), a full systems review should be performed and documented.
Red-Flag Symptoms & Safety Netting
Part of a thorough history includes actively screening for red-flag symptoms that may indicate serious underlying pathology and require urgent investigation or referral.
| System | Red-Flag Features | Possible Serious Diagnosis |
|---|---|---|
| Cardiovascular | Exertional chest pain with radiation; syncope during exercise; new systolic murmur with dyspnoea | Acute coronary syndrome, aortic stenosis, hypertrophic cardiomyopathy |
| Respiratory | Haemoptysis; unilateral leg swelling with pleuritic chest pain; progressive dyspnoea in a smoker | Pulmonary embolism, lung cancer, mesothelioma |
| Gastrointestinal | Unintentional weight loss; progressive dysphagia; change in bowel habit >6 weeks in age >50; melaena | Colorectal cancer, oesophageal cancer, upper GI bleed |
| Neurological | Thunderclap headache; new focal neurological deficit; seizures in an adult without prior history | Subarachnoid haemorrhage, stroke, space-occupying lesion |
| Endocrine | Polyuria/polydipsia with weight loss; confusion with diaphoresis; neck swelling with dysphagia | Diabetic ketoacidosis, hypoglycaemia, thyroid malignancy |
Safety netting is a medicolegal and clinical obligation. Every consultation should end with: (1) a clear explanation of the working diagnosis; (2) explicit advice on what to watch for (red flags); (3) a timeframe for review or expected improvement; and (4) instructions on when and where to seek further care (e.g., "If the pain becomes severe or you develop a fever, go to your nearest emergency department or call 000").
Documentation & Record Keeping
The clinical record is a medicolegal document, a communication tool for multidisciplinary teams, and a requirement for Medicare billing. The RACGP Standards for General Practices (5th edition) and the ACSQHC NSQHS Standards mandate accurate, contemporaneous documentation.
Common Documentation Formats
SOAP Format
S β Subjective (patient's account, symptoms, history)
O β Objective (examination findings, investigations, vital signs)
A β Assessment (working diagnosis, differential diagnoses)
P β Plan (investigations, treatment, referrals, follow-up, safety netting)
Problem-Based Format
Each active problem is listed as a heading, with relevant subjective, objective, assessment, and plan information documented beneath. Particularly useful for patients with multiple chronic conditions (multimorbidity).
Minimum Documentation Standards
- Date and time of consultation
- Clinician name and designation (e.g., Dr Jane Smith, FRACGP)
- Patient identification (name, DOB, MRN or IHI in hospital settings)
- Presenting complaint in patient's own words
- Relevant history (positive and pertinent negative findings)
- Examination findings
- Investigation results (or pending)
- Working diagnosis / differential diagnoses
- Management plan including medications (name, dose, frequency, duration), referrals, follow-up arrangements
- Patient education and safety-netting advice provided
- Consent (documented where relevant β e.g., procedures, disclosure of information)
Special Populations & Modifications
Paediatric
Collateral history is essential β rely on parents/carers for details in pre-verbal or young children. In adolescents, balance confidentiality with parental involvement (mature minor doctrine applies in Australian jurisdictions).
Developmental history: milestones (gross motor, fine motor, language, social), school performance, behaviour concerns.
Antenatal/perinatal history: maternal health, gestational age, birth weight, NICU admission, neonatal screening results.
Immunisation status: check the Australian Immunisation Register (AIR); children without up-to-date immunisations may be subject to No Jab No Pay (Social Services Legislation Amendment) provisions.
Growth parameters: plot on WHO growth charts (0β2 years) or CDC/Australian charts (2β18 years).
Pregnancy
Obstetric history: gravida/para, gestational age, antenatal care provider, complications, birth plan.
Screen for: pre-eclampsia risk factors, gestational diabetes, Group B Streptococcus status, blood group and antibodies, rhesus status, rubella/immunity, hepatitis B/C, HIV, syphilis.
Medication safety: review all medications for teratogenicity (use ADEC pregnancy categories or TGA's AusPregnancy register).
Psychosocial screening: Edinburgh Postnatal Depression Scale (EPDS), domestic and family violence, substance use, social supports.
Elderly
Cognitive assessment: screen with MMSE or MoCA if cognitive decline suspected; assess capacity for consent (four-abilities test under Australian common law).
Functional assessment: ADLs and IADLs (instrumental activities of daily living); consider Aged Care Assessment Team (ACAT) / My Aged Care referral.
Falls risk: history of falls in the past 12 months; medications contributing to falls (benzodiazepines, antihypertensives, anticholinergics).
Polypharmacy: review for deprescribing opportunities using tools such as the Beers Criteria or STOPP/START criteria.
Advance care planning: ask about advance care directives, substitute decision-makers, resuscitation wishes.
Frailty screening: Clinical Frailty Scale or FRAIL questionnaire to guide shared decision-making.
Renal Impairment
Medication history is critical: identify nephrotoxic agents (NSAIDs, aminoglycosides, lithium, contrast media, ACE inhibitors/ARBs in renal artery stenosis).
Renal dosing: calculate eGFR (CKD-EPI equation) and adjust drug doses accordingly; document baseline creatinine.
CKD staging: eGFR + albuminuria (ACR) per KDIGO guidelines to guide management intensity and referral to nephrology.
Hepatic Impairment
Hepatotoxic agents: paracetamol (even at therapeutic doses in chronic liver disease), statins, anti-tuberculous drugs, methotrexate.
Assess severity: Child-Pugh score to guide medication safety; coagulopathy (INR), albumin, bilirubin.
Screen for variceal bleeding risk in portal hypertension; ensure hepatitis B vaccination is up to date where appropriate.
Immunocompromised
Cause of immunosuppression: HIV (CD4 count, viral load, ART regimen), chemotherapy, biologics (TNF inhibitors, rituximab), corticosteroids (β₯20 mg prednisolone/day for β₯14 days), solid organ transplant (ISHLT guidelines).
Infection risk stratification: opportunistic infections depending on degree of immunosuppression β Pneumocystis jirovecii, CMV, cryptococcal meningitis, atypical mycobacteria.
Vaccination: live vaccines contraindicated; review status per Australian Immunisation Handbook for immunocompromised individuals.
Prophylaxis: trimethoprim-sulfamethoxazole for PJP when CD4 <200; antifungal prophylaxis post-transplant.
Aboriginal and Torres Strait Islander Health Considerations
History taking with Aboriginal and Torres Strait Islander patients requires cultural safety, humility, and awareness of the social and historical determinants of health that disproportionately affect Indigenous Australians. The following principles and practical adjustments are recommended by the RACGP, AIHW, and RHDAustralia.
Core Principles
- Cultural safety over cultural awareness: cultural safety is defined by the patient, not the clinician. Reflect on your own biases, avoid assumptions, and ask open-ended questions about cultural preferences.
- Allow time: consultations with Aboriginal and Torres Strait Islander patients may require longer appointments (MBS Level C/D or longer). Rushed consultations erode trust and lead to incomplete histories.
- Use a "yarning" approach: storytelling and non-linear conversation are culturally appropriate communication styles. Begin with social conversation before transitioning to clinical questions.
- Involve Aboriginal Health Workers/Practitioners (AHW/AHP): AHWs and AHPs can facilitate communication, provide cultural brokerage, and assist with health literacy. Their role is funded through Indigenous-specific MBS items and state/territory health services.
- Family and community: health decisions are often made collectively. With the patient's consent, involve family members in the consultation. Be aware that the patient may wish to have an Elder or senior family member present.
Specific History-Taking Considerations
π References
- 1. Hampton JR, Harrison MJ, Mitchell JR, Prichard JS, Seymour C. Relative contributions of history-taking, physical examination, and laboratory investigation to diagnosis and management of medical outpatients. Br Med J. 1975;2(5969):486-489. doi:10.1136/bmj.2.5969.486
- 2. Royal Australian College of General Practitioners (RACGP). Standards for General Practices. 5th edition. Melbourne: RACGP; 2020.
- 3. Kurtz SM, Silverman JD, Draper J. Teaching and Learning Communication Skills in Medicine. 2nd edition. Oxford: Radcliffe Publishing; 2005. (Calgary-Cambridge model.)
- 4. Heritage J, Robinson JD, Elliott MN, Beckett M, Wilkes M. Reducing patients' unmet concerns in primary care: the difference one word can make. J Gen Intern Med. 2007;22(10):1429-1433. doi:10.1007/s11606-007-0279-0
- 5. Australian Commission on Safety and Quality in Health Care (ACSQHC). National Safety and Quality Health Service Standards. 2nd edition. Sydney: ACSQHC; 2021.
- 6. Austroads. Assessing Fitness to Drive. Sydney: Austroads; 2022. Available at: australasianaid.com/assessing-fitness-to-drive.
- 7. Australian Institute of Health and Welfare (AIHW). Aboriginal and Torres Strait Islander Health Performance Framework. Canberra: AIHW; 2023.
- 8. RHDAustralia (Rheumatic Heart Disease Australia). Australian Guidelines for Prevention, Diagnosis and Management of Acute Rheumatic Fever and Rheumatic Heart Disease. 3rd edition. Darwin: RHDAustralia; 2020.
- 9. Australian Sexual Health Medicine (ASHM). Australian STI Management Guidelines for Use in Primary Care. Sydney: ASHM; 2023. Available at: sti.guidelines.org.au.
- 10. Australian Immunisation Handbook. Australian Government Department of Health and Aged Care. Canberra; 2024. Available at: health.gov.au/topics/immunisation/handbook.
- 11. Talley NJ, O'Connor S. Clinical Examination: A Systematic Guide to Physical Diagnosis. 8th edition. Sydney: Elsevier; 2018.
- 12. Berg KM, Arnsten JH, Sacajiu G, Karasz A. Providers' perspectives on the role of patient adherence in HIV treatment. AIDS Patient Care STDS. 2006;20(12):848-858. (IDEAS model of patient-provider communication.)
- 13. Bickley LS, Szilagyi PG. Bates' Guide to Physical Examination and History Taking. 13th edition. Philadelphia: Wolters Kluwer; 2021.
- 14. Royal Australian College of General Practitioners (RACGP). Management of Knee Osteoarthritis. East Melbourne: RACGP; 2018. (STAR T Back screening tool reference context.)
- 15. National Aboriginal Community Controlled Health Organisation (NACCHO). National Guide to a Preventive Health Assessment for Aboriginal and Torres Strait Islander People. 3rd edition. Melbourne: RACGP/NACCHO; 2018.