Complete Health History 11/25/2010

The purpose of health history is to collect subjective data

Biographic Data
 Name, address and phone number, age and birth date, birthplace,
gender, marital status, race, ethnic origin, occupation, usual and
present illness, language and communication needs
Source of History
 Who furnishes the information
 How reliable the informant seems and how willing he or she is to
communicate
 Note any special circumstance (e.g. interpreter)
Reason for seeking care
 Brief spontaneous statement in the person’s own words that
describes the reason for the visit
 Find out why the person is seeking care NOW
Present Health or History of Present Illness
 For a well person- short statement about general state of health
 For the ill person- chronologic record of the reason for seeking care,
from the time the symptom first started until now
 Final summary of any symptom should include:
o Eight Critical Characteristics
 Location
 be specific; ask to point
 Character or quality
 burning? Sharp? Dull? Chaing?
 Quantity or severity
 attempt to quantify; scale
 Timing
 onset, duration, frequency
 Setting
  where was the person when symptom started?
 Aggravating or relieving factors-
 what makes pain worse?
 What relieves it?
 Associated factors
 Review the body system related to this symptom
now rather than wait for the ROS
 Patient’s perception
 Find out the meaning of the symptom by asking
how it affects daily activities
o PQRSTU
 Provocative or palliative?
 Quality or quantity?
 Region or radiation
 Severity scale
 Timing
 Understand patient’s perception
Past Health
 Childhood illnesses
 Accidents or injuries
 Serious or chronic illnesses
 Hospitalizations
 Operations
o Type or surgery, date, name of surgeon, hospital
 Obstetric history
o # of pregnancies (gravidity)
o # of deliveries (full term, preterm, and abortions)
 Immunizations
 o Note the date of the last tetanus immunization, last TB skin
test, and last flu shot
 Last examination date
 Allergies
o Note both allergen and reaction
 Current medications
o All prescription and OTC medications
Family History
 Genetic plays a significant role
 Ask for family history of heart disease, HB pressure, stroke,
diabetes, blood disorders, sickle-cell anemia, arthritis, allergies,
obesity, alcoholism, mental illness, seizure disorder, kidney disease
and TB
Review of Systems
 Purpose
o Evaluate the past and present health state of each body
system
o Double-check in case any significant data were omitted in the
present illness section
o Evaluate health promotion practices
 History should be limited to patients statements, or subjective data
Functional Assessment (including ADL)
 Measures a person’s self-care ability
11/25/2010
11/25/2010