Running head: HEALTH HISTORY 1
1
Health History Guide
Name
College
HEALTH HISTORY 2
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 4
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
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