Name: Clinical History Taking 4
Creator: Leya Luhar
Keywords: History Taking,Nervous system,Pain

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Scenarios

By Leya Luhar • October 20, 2026 • Last reviewed: 2026-10-20 •

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Summary Beginner

A patient has been booked in to see the practice pharmacist by their GP, who has asked for a full clinical history to be taken before the GP decides what to do next.

The student must take a structured clinical history covering the presenting complaint, red flags, medical, medication and social history, then summarise and explain the next steps to the patient.

You will need a student pharmacist and an actor playing the patient for this scenario. The patient can be played by a male or female actor.

Revision Topics

Be aware, this may reveal any answers!

Student Instructions

Actor Instructions

This may reveal scenario objectives!

You are Ravi Mistry (RAH-vee, MISS-tree) or Rina Mistry (REE-nah, MISS-tree).

Opening statement: ‘Hello. The doctor said you’d go through these headaches I keep getting with me.’

Patient information:

To be given if the student asks.

Name: Ravi Mistry or Rina Mistry
Date of Birth: 06/10/1990
Age: 36
Address: 14 Compton Grove, Wolverhampton, WV3 9DT
Past medical history:
- ‘Nothing really. I had my appendix out when I was 12.’
Medication history:
- ‘I don’t take anything from the doctor.’
- If asked about bought medicines:
  - ‘I started with paracetamol, 2 tablets when I needed them, for the first couple of weeks. It didn’t really touch it, so for the last month I’ve been taking co-codamol, the regular ones from the chemist. 2 tablets, most days, maybe five 5 a week.’
  - If asked whether you take them together: ‘No, one or the other, never both.’
- If asked about herbal remedies or supplements: ‘No herbal things. I take a multivitamin most days.’
Allergies:
- ‘No allergies that I know of.’
Symptoms:
- Where: ‘Across my forehead and both sides, like a tight band round my head.’
- Started: ‘About six weeks ago, when work got really busy. It came on gradually.’
- What it feels like: ‘A dull, pressing ache. It’s not throbbing.’
- Spreads: ‘Sometimes into the back of my neck.’
- When: ‘Most days now. It’s there by mid-afternoon and lasts a few hours.’
- Worse or better: ‘Worse after a long day on the computer, or if I skip lunch. The painkillers take the edge off for a couple of hours.’
- How bad: ‘About a 5 out of 10.’
- Before and since: ‘I’ve never really had headaches before. They’re getting more frequent; at first it was a couple of times a week, now it’s most days.’
- No other symptoms
Lifestyle factors:
- Job: ‘I’m an accountant. Since we took on a big new client over the summer I’ve been at the computer ten hours a day.’
- Home: ‘I live with my husband (or wife) and our two kids, they’re 4 and 7.’
- Hobbies: ‘Badminton on Saturdays, and I like cooking.’
- Travel: ‘No, we haven’t been abroad this year.’
- Smoking: ‘I’ve never smoked.’
- Alcohol: ‘Just a glass of wine at the weekend.’
- Recreational drugs: ‘No, never.’
- Caffeine: ‘Probably five or six coffees a day at the moment.’
- Sleep: ‘About six hours. I’m up late finishing work.’
- Meals and drinks: ‘I skip lunch most days, and I don’t drink much water.’
If the pharmacist asks further questions:
- Family history: ‘My mum gets migraines. My dad has high blood pressure.’
- Effect on daily life: ‘I’m struggling to concentrate at work in the afternoons.’
- What you think it is: ‘Probably stress from work.’
- Worries: ‘My friend’s dad had a brain tumour and it started with headaches. That’s in the back of my mind.’
- What you hoped for: ‘Something stronger to get rid of them.’
- Mood ‘Honestly, I’m fed up, and a bit anxious.’
- Eyesight: ‘I’m supposed to wear glasses for the computer but I keep forgetting them. My last eye test was about three years ago.’
- Recent illness: ‘No colds or anything.’
- Taking anyone else’s medicines: ‘No.’
- Contraception (female actor only): ‘I have the implant.’

Acting notes:

Use everyday language.
Answer only what you are asked, one thing at a time.
If the student uses a term you do not understand: ‘Sorry, what does that mean?’

Mark Scheme

Introduction

0 / 3

Introduces themselves by name and states their role as a pharmacist

Example wording: ‘Hello, my name is Sam and I’m one of the pharmacists who works with the GPs here.’

Confirms the patient’s identity using at least two identifiers: full name plus date of birth or address

Example wording: ‘Before we start, can I just check your full name and your date of birth, please?’

Explains the purpose of the consultation and gains verbal consent to take a clinical history

Example wording: ‘Your GP has asked me to go through some questions with you about what’s been happening and your general health, and then I’ll share what we discuss with them. Is that all right with you?’ Explaining the purpose without asking does not earn the mark.

Medical History

0 / 6

Confirms the patient’s past medical history

Example wording: ‘Do you have any medical conditions that you see the doctor or nurse about?’ and ‘Have you ever had any operations or been in hospital?’ Asking about operations is good practice but is not required.

Confirms the patient’s current medicines, asking about both prescribed medicines and medicines bought over the counter

Example wording: ‘Are you taking any medicines at the moment, either ones the GP prescribes or ones you buy yourself from a pharmacy or supermarket?’ and ‘How often are you taking that?’ The student must find out about the co-codamol and roughly how often it is taken (most days).

Confirms the patient tried paracetamol first and it did not help enough, and that the co-codamol only partly helps

Example wording: ‘Have the painkillers helped at all?’

Asks about recreational or illicit drug use

Example wording: ‘This is something I ask everyone. Do you use any recreational drugs, such as cannabis?’

Asks about medicines in other forms: at least two of creams or ointments, inhalers, nasal sprays and eye drops

Example wording: ‘Some people don’t think of these as medicines, so I always ask: do you use any creams, inhalers, nose sprays or eye drops?’

Asks about allergies (no known allergies)

Example wording: ‘Do you have any allergies to medicines, foods or anything else?’ If an allergy is disclosed, asking what happened earns no extra mark but is good practice.

Social History

0 / 6

Confirms family history (

Example wording: ‘Do any medical conditions run in your family, for example in your parents, brothers or sisters?’

Confirms living arrangements

Example wording: ‘Who do you live with at home?’

Confirms occupation

Example wording: ‘What do you do for work?’

Asks about recent travel

Example wording: ‘Have you travelled anywhere recently, in the UK or abroad?’

Asks about hobbies

Example wording: ‘What do you like to do in your spare time?’

Asks about smoking and alcohol

Example wording: ‘Do you smoke, or have you ever smoked?’ and ‘How much alcohol would you drink in a typical week?’

Closing Consultation

0 / 4

Summarises the findings back to the patient, including the main problem, how long it has been going on, and at least two other relevant points from the history

Example wording: ‘So just to check I’ve understood: you’ve had headaches for about six weeks, across your forehead like a tight band, and they’re now happening most days. Paracetamol didn’t help, and you’ve been taking co-codamol on most days for the last four weeks. Work has been very busy, and you’re worried it could be something serious. Is that right?’ Does not earn the mark: ‘So that’s everything, thank you’ with no content, or a summary of the presenting complaint alone.

Asks if the patient has anything further to add or any questions

Example wording: ‘Is there anything else you’d like to tell me, or anything you’d like to ask before we finish?’

Explains the next steps: they will discuss the history with the GP, and tells the patient how and when they will hear back

Example wording: ‘Thank you. I’m going to talk everything through with your GP today, including how often you’ve been needing the co-codamol, and either the GP or I will ring you this afternoon to let you know the plan. Is that OK?’ Accept another appropriate plan, for example asking the GP to join the consultation now. Both parts are needed: discussing with the GP, and how or when the patient will hear back. Does not earn the mark: ‘I’ll pass this on’ with no indication of what happens next. Mentioning that frequent painkillers can sometimes cause headaches is not required and earns no extra mark.

Thanks the patient for their time, says goodbye or closes with another polite phrase

Example wording: ‘Thank you for going through all of that with me. Take care, and we’ll speak later today.’

Patient Safety

0 / 1

Keeps the patient safe throughout the consultation: stays within their role as a pharmacist who is not a prescriber and gives no advice that could cause harm

Forfeited by any of the following: advising the patient to take more co-codamol, or a stronger codeine product; advising the patient to take paracetamol and co-codamol together; promising or recommending a prescription only medicine; telling the patient the headaches are definitely not serious when red flags have not been asked about; dismissing a red flag the patient reports in error. Advice is not required in this station. A student who gives safe, general advice earns no extra marks and is not penalised.

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Referral Criteria for Headache

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