Description
select a client from whom to elicit a complete health history. The client may be a friend, classmate or family member. They should be identified only by initials to protect confidentiality.
Running head: HEALTH HISTORY
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Health History Guide
Name
College
1
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
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Source of history
Reliability
Chief complaints/reason for visit
Present illness:
Time of onset
Date, time…?
Type of onset
How: Sudden? Gradual?
Original Source
Triggers, what were you doing?
Severity
Interfere with ADL’s?
Radiation
Pain, direction it travels?
Time relationship
How often, when?
Duration
How long an episode?
Course
Getting better, worse?
Association
Lead to others?
Source of relief
Changes in medications, diet?
Source of aggravation
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
Family history: (Age and health or age and cause of death)
Maternal/Paternal Grandparents
Parents
Aunts/Uncles
Siblings
Spouse
Children
Genogram
5
HEALTH HISTORY
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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
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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, postmenopausal 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
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
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HEALTH HISTORY
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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
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
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HEALTH HISTORY
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.
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HEALTH HISTORY
Nutritional data: ( see attached)
Identified risk factors:
Health promotion activities:
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HEALTH HISTORY
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NUTRITIONAL ASSESSMENT
Client’s Height _______________
Weight ______________________
Recommended weight
Projected Calories
_____________ ——24-Hour Diet Recall;
TIME
BREAKFAST
LUNCH
DINNER
SNACK
FOOD EATEN
CALORIE AMOUNT
HEALTH HISTORY
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FOOD
CATEGORIES
SERVINGS
NEEDED
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
SERVINGS EATEN
DIFFERENCE
Fats and oils
Other foods
Comments:
Suggestions Made:
Increased calories
Decrease sugar
___________
____________
Increase number of meals __________
Decrease fat
______________
Increase fiber
______________
Other
______________
Referred to food programs
Client’s evaluation of own diet (circle one):
Excellent
Good
Fair
Poor
HEALTH HISTORY
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References
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