Running

head: HEALTH HISTORY

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Health History Guide

Name

College

HEALTH HISTORY

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Health history

Identifying data

Date of history

Examiner

Name

Address

Phone number

Age

Sex

Race

Place of Birth

Marital Status

Significant Other

Employer

Occupation

Religion

Primary Language

Secondary Language

Source of referral

HEALTH HISTORY 3

Source of history

Reliability

Chief complaints/reason for visit

Present illness:

Time of onset

Type of onset

Original Source

Severity

Radiation

Time relationship

Duration

Course

Association

Source of relief

Source of aggravation

Date, time…?

How: Sudden? Gradual?

Triggers, what were you doing?

Interfere with ADL’s?

Pain, direction it travels?

How often, when?

How long an episode?

Getting better, worse?

Lead to others?

Changes in medications, diet?

What makes it worse?

HEALTH HISTORY

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Past history

General State of Health:

Childhood Illnesses: (measles, mumps, rubella, whooping cough, chicken pox, scarlet

fever, rheumatic fever, polio)

Adult Illnesses: (HTN, CAD, DM, Lung…)

Psychiatric Illnesses

Accidents and Injuries

Operations

Hospitalizations

Obstetric

Current health status

Current Medications (prescription or OTC)

Allergies (food/medications)

Screening Tests (PPD, Pap, Mammograms, stools…)

Immunizations (tetanus, pertussis, diphtheria, polio, mumps, measles, rubella, influenza,

Hepatitis B, Flu, Pneumococcal)

Obstetric

HEALTH HISTORY 5

Family history: (Age and health or age and cause of death)

Maternal/Paternal Grandparents

Parents

Aunts/Uncles

Siblings

Spouse

Children

Genogram

HEALTH HISTORY 6

Review of systems

General: Overall state of health, changes in ADL’s, weight, fatigue, fever, increased

infections.

Skin: Rashes, lumps, sores, itching, dryness, color change changes in hair or nails.

NEUROLOGIC: Seizures, headaches, paralysis. Numbness, weakness, syncope, restless,

tremors, blackouts.

Eyes: Vision, glasses, contacts, ? Last eye exam, pain, redness, excessive tearing, double

vision, blurred vision, glaucoma, cataracts.

Ears: Hearing, tinnitus, vertigo, earaches, infections, discharge ? Hearing aids.

Nose and Sinuses: Frequent colds, nasal stuffing, discharge, hay fever.

Mouth and throat: Condition of gums and teeth, dentures, last exam, dry mouth, frequent

sore throats hoarseness.

Neck: Lumps, “swollen glands”, goiter, pain, stiffness.

Breast: Lumps, pain, nipple discharge? Self-exam.

Respiratory: Dyspnea, SOB, pain, wheezing, crackles, orthopnea, (?) Pillows, cough,

sputum (color, quantity), emphysema, bronchitis, asthma, URI, chest x-ray.

HEALTH HISTORY 7

Cardiac: Heart trouble, high blood pressure, rheumatic heart fever, murmurs, palpitations,

chest pain, dyspnea. paroxysmal nocturnal dyspnea, edema, EKG, other heart test results.

Gastrointestinal: Trouble swallowing, heartburn, appetite, nausea, vomiting. Frequency

of bowel movements, change in pattern, rectal bleeding or black tarry stools,

hemorrhoids, constipation. diarrhea. Abdominal pain, food intolerance, excessive

belching or passing gas. Jaundice, liver or gallbladder trouble, hepatitis.

Urinary: Frequency, polyuria, nocturia, burning or pain on urination, hematuria, urgency,

hesitancy, dribbling, UTI’s, stones.

Genital:

Male: Hernia, discharge, testicular pain or masses, history of STD’s and treatments,

Sexual preference, interest, satisfaction, and problems.

Female: Age of menarche; regularity, frequency, and duration, amount of

bleeding.bleeding between periods or after intercourse, last menstrual period,

dysmenorrhea, premenstrual tension, age of menopause, menopausal symptoms, post-

menopausal bleeding. If born before 1971, exposed to DES from maternal use.

Discharge, itching, sores, lumps, STD’s and treatment. Number of pregnancies,

deliveries, abortions, complications of pregnancy, birth control methods. Sexual

preference, interest, function, satisfaction.

Peripheral vascular: Intermittent claudication, leg cramps, varicose veins, past clots.

Musculoskeletal: Muscle or joint pains, stiffness, arthritis, gout, backache.

Hematologic: Anemia, easy bruising or bleeding, past transfusions and any reaction.

Endocrine: Thyroid trouble, heat or cold intolerance, excessive sweating, diabetes,

excessive thirst or hunger, polyuria.

Psychiatric: Nervousness, tension, moods, depression, memory

HEALTH HISTORY 8

Functional Assessment (Including Activities of Daily Living)

Self-Esteem, Self-Concept

Financial Status

Value-belief system

Self-care behaviors

Activity/Exercise

ADL’s

Leisure activities

Exercise pattern

Other self-care behaviors

Sleep/Rest

Nutrition/Elimination

Is this menu pattern typical of most days?

Who buys food?

Who prepares food?

Finances adequate for food?

Who is present at mealtimes?

Other self-care behaviors

Interpersonal relationships/resources

Describe own role in family

How getting along with family, friend, coworkers, classmates

Get support with a problem from

How much daily time spent alone?

Is it pleasurable or isolating?

Other self-care behaviors

HEALTH HISTORY 9

Coping and Stress Management

Describe stress in life now

Change in past year

Methods used to relieve stress

Are these methods useful?

Personal Habits

Daily intake caffeine (coffee, tea, colas)

Smoke cigarettes

Number packs per day

Daily use for how many years

Age started

Ever tried to quit

How did it go?

Drink alcohol No

Date last alcohol use

Amount of alcohol that episode

Out of last 30 days, on how many days had alcohol?

Ever had a drinking problem?

Any use of street drugs? Specifically

Marijuana Amphetamines Heroin

Cocaine Barbiturates Other

Crack Cocaine LSD

Ever been in treatment for drugs or alcohol?

HEALTH HISTORY 10

Environment/Hazards

Housing and neighborhood (type of structure, live alone, know neighbors)

Safety of area?

Adequate heat and utilities?

Involvement in community services

Hazards at workplace or home

Use of seatbelts

Travel or residence in other countries

Military service in other countries

Self-care behaviors

Occupational Health

Jobs held

Satisfaction with present and past employment

Current place of employment

Please describe your job

Work with any health hazards?

Any equipment at work designed to reduce your exposure?

Any programs designed to monitor your exposure?

Any health problems that you think are related to your job?

What do you like or dislike about your job?

Perception of own health

How do you define health

View of own health now

Reaction to illness

Coping patterns/mechanisms

HEALTH HISTORY 11

Value of health

What are your concerns

What do you expect will happen to your health in future?

Your health goals

Your expectations of nurses and physicians

Educational level

Highest degree or grade level attained

Judgment of intellect relative to age

Patterns of health care

Dental care

Preventive care

Emergency care

Developmental data:

Summary of developmental data and current functioning.

Use Erikson’s stages of development.

HEALTH HISTORY 12

Nutritional data: ( see attached)

Identified risk factors:

Health promotion activities:

HEALTH HISTORY 13

NUTRITIONAL ASSESSMENT

Recommended weight

24-Hour Diet Recall;

TIME FOOD EATEN CALORIE AMOUNT

BREAKFAST

LUNCH

DINNER

SNACK

Client’s Height _______________ Weight ______________________

Projected Calories

_____________ ——-

HEALTH HISTORY 14

FOOD

CATEGORIES

SERVINGS

NEEDED

SERVINGS EATEN

DIFFERENCE

Animal Protein

2

Vegetable Protein

2

Dairy products

calcium rich

4

Whole grains, breads

and cereals

4

Vitamin c-rich foods

1-2

Green.leafy

vegetables

1-2

Other fruits and

vegetables

2

Fats and oils

Other foods

Comments:

Suggestions Made:

Increased calories ___________ Decrease fat ______________

Decrease sugar ____________ Increase fiber ______________

Increase number of meals __________ Other ______________

Referred to food programs

Client’s evaluation of own diet (circle one):

Excellent Good Fair Poor

HEALTH HISTORY 15

References