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The Comprehensive

Health History
The purpose of health history
is to collect subjective data
what the patient says about
himself or herself. The history is
combined with objective data
from the physical examination
and laboratory studies to form
the data base.

The
health
history
provides
a
comprehensive portrait of the patients past
and present health. The components of a
health history are as follows:
1. Biographic Data
2. Reason for Seeking Care (Chief complaint
of present illness)
3. Present health or history of present illness
4. Current medications
5. Family history
6. Review of systems
7. Functional assessment of activities of daily
living (ADLs)

The Health History The Adult


1. Biographic Data
. Name
. Address and phone number
. Age and birth date
. Birthplace
. Gender
. Marital Status
. Race, Ethnic Origin
. Occupation (usual and present an
illness or disability may have
prompted change in occupation)

Language and communication needs


(primary language and authorized
representative should be recorded; if
the patient does not speak English or
Filipino/Tagalog,
specify
the
language/dialect spoken (e.g. speaks
Ilocano only, speaks Korean only).
Source of History
1. Record
who
furnishes
the
information
(e.g.
the
patient,
relative or friend).

2. Judge how reliable the information seems and


how willing he or she is to communicate. What
is reliable? A reliable person always givers the
same answers, even when questions are
rephrased or are repeated later in the interview.
3. Note any special circumstances, such as the use
of an interpreter.
Examples:
Patient herself, who seems reliable.
Patients son, Joseph Guerrero, who seems
reliable.
Mrs. Cynthia Aguilar, interpreter for Anusha
Motomal who does not speak Filipino or
English.

2. Reason for Seeking Care (Chief


Complaint)
. This is a brief spontaneous
statement in the patients own
words that describes the reason
for the visit. It states one (possibly
two) signs or symptoms and their
duration.
. A sign is an objective abnormality
that can be detected on physical
examination or in laboratory
studies.

The chief complaint is enclosed in quotation


marks to indicate the persons exact words.
This is now replaced with reason for seeking
care that incorporates wellness needs.
Examples:
Chest pain for 2 hours.
Earache and fussy all night.
Dizziness and ringing of the right ear.
Need yearly physical examination for work.
The chief complaint is not a diagnostic
statement. Avoid translating it into terms of
a medical diagnosis (e.g., increasing
shortness of breath for four hours, not
emphysema.

3. Present Health or History of


Present Illness
. For the well person, this is a short
statement about general state of
health.
. For the ill person, this is a
chronological record of the reason
for seeking care, from the time the
symptom first started until now.
Example: Please tell me all about
your headache, from the time it
started until the time you came to

The final summary of any symptom should


include the following eight critical
characteristics:
a. Location
b. Quality or Character. This calls for specific
descriptive terms such as burning, sharp,
dull, aching, gnawing, throbbing, shooting,
viselike. Use similes Does blood in the
stool look like sticky tar? Does blood in the
vomitus look like coffee-grounds?
c. Quantity or Severity. Attempt to quantify the
sign and symptom, e.g., profuse menstrual
flow soaking five pads per hour.

d.Timing (Onset, Duration, Frequency).


. When did the symptom first appear? Or state
specifically how long ago the symptom
started prior to arrival.
. How long did the symptom last?
. Was it steady (constant) or did it come and
go during that time (intermittent)?
e.Setting. Where was the person or what was the
person doing when the symptom started? What
brings it on?
Example: Did you notice the chest pain after
carrying a heavy load, or did the pain start by
itself?

f. Aggravating or Relieving Factors.


.What makes the pain worse?
Example: Is it aggravated by
weather, activity, food, medication,
time of day, season and so on?
.What relieves it (e.g., rest,
medication, ice pack)?
.What is the effect of treatment?
Example: What have you tried? or
What seems to help?

g. Associated Factors. Is the primary


symptom associated with any others
(e.g., urinary frequency and burning
associated with fever and chills?)
Review the body system related to
this symptom now rather than wait
for the review of systems.
h. Patients Perception. Find out the
meaning of the symptom by asking
how it affects daily activities. Also
ask directly, What do you think it
means? This is crucial because it

To help remember all the points, organize this


question sequence into the mnemonic PQRSTU.
P: Provocative or Palliative. What brings it on? What
were you doing when you first notice it? What
makes it better? Worse?
Q: Quality or Quantity. How does it look, feel, sound?
How intense/severe is it?
R: Region or Radiation. Where is it? Does it spread
anywhere?
S: Severity Scale. How bad is it (on a scale of 1 to
10?) Is it getting better, worse, staying the same?
T: Timing. Onset exactly when did it first occur?
Duration how long did it last? Frequency how
often does it occur?
U: Understand Patients Perception of the Problem.
What do you think it means?

4. Past Health History


. Past health events may have residual effects
on the current state of health.
. Previous experience with illness may give
clues on how the patient responds to illness
and to the significance of illness for him or
her.
a. Childhood Illnesses. Measles, mumps,
rubella, chicken pox, pertussis and strep
throat.
b. Accidents or injuries. Auto accidents,
fractures, head injuries, burns, falls.
c. Serious or Chronic Illnesses. Diabetes,
hypertension,
heart
disease,
cancer,
seizure disorder.

d. Hospitalizations. Cause, name of


hospital, how the condition was
treated, how long the person was
hospitalized and name of the
physician.
e. Operations. Type of surgery, date,
name of the surgeon, name of
hospital and how the person
recovered.
f. Obstetric
History.
Number
of
pregnancies (Gravidity), number of
deliveries in which the fetus reached

g. Immunizations: Measles Mumps


Rubella (MMR), polio, diphtheria
pertussis tetanus (DPT), hepatitis
B, human papilloma virus (HPV),
haemophilus influenza type b (Hib),
pneumococcal vaccine. Note the
date
of
the
last
tetanus
immunization, last tuberculosis skin
test and last flu shot.
h. Last Examination Date: Physical,
dental,
vision,
hearing,
electrocardiogram (ECG), chest X-

5. Current Medications (Medication


Reconciliation)
. Note all prescription and over-the-counter (OTC)
medications and herbal remedies.
. Ask specifically for vitamins, birth control pills,
aspirin and antacids.
. For each medication, note the name, dose and
schedule and ask, How often do you take it each
day? What is it for? and How long have you
been taking it?
. Prescribed medications may have adverse
interactions with OTCs and herbal medications.
. This also ensures evaluation of medications
taken by the patient by the physician either to
continue the medication unchanged, to continue
but change the dose, or to discontinue the
medication.

6. Family History
. Ask about the age and health or age and
cause of death of blood relatives such as
parents, grandparents, siblings. These data
may have genetic significance for the
patient.
. Ask about close family members such as
spouse and children. If there is prolonged
contact with any communicable disease
(e.g., husband has pulmonary tuberculosis).
. Ask family history of heart disease, high
blood pressure, stroke, diabetes, blood
disorders,
cancer,
anemia,
arthritis,
allergies, obesity, alcoholism, mental illness,
seizure disorder, kidney disease and
tuberculosis.

7. Review of Systems (ROS)


. The order of the examination is from
head to toe.
. Remember, that the health history should
be limited to patient statements or
subjective data factors that the
person says were or were not present.
General Overall Health State
. Present weight (gain or loss, period of
time, by diet or other factors), fatigue,
weakness or malaise, fever, chills, sweats,
or night sweats.

Skin
History of skin disease (eczema,
psoriasis), change in pigmentation,
texture or color, change in mole,
excessive
dryness,
sweating,
pruritus, hair growth and distribution,
excessive bruising.
Hair
Recent loss, change in texture. Nails:
change in shape, color or brittleness.
Health promotion: amount of sun
exposure, method of self care for

Head
Any
unusually
frequent
or
severe
headache, any head injury, dizziness,
vertigo, syncope.
Eyes
Difficulty with vision (decreased activity,
blurring, blind spots), eye pain, diplopia
(double vision), redness or swelling,
watering
or
discharge,
glaucoma,
cataracts, photophobia, itching.
Health Promotion: Wears glasses or
contacts; last vision check or glaucoma
test; and how is he/she coping with loss of
vision if any.

Ears
Earaches,
infections,
discharge
and
its
characteristics, tinnitus (ringing of the ears) or
vertigo (sensation of spinning of the room or
self).
Health Promotion: Hearing loss, hearing aid use,
how loss affects daily life, any exposure to
environmental noise, and method of cleaning
ears.
Nose and Sinuses
Discharge and its characteristics, any unusually
frequent or severe colds, sinus pain, nasal
obstruction, nosebleeds, allergies or hay fever, or
change in the sense of smell.

Mouth and Throat


Mouth pain, frequent sore throat,
bleeding gums, toothache, lesion in
mouth
and
tongue,
dysphagia
(difficulty in swallowing), hoarseness
or voice change, tonsillectomy,
altered taste.
Health Promotion: Pattern of daily
dental care, use of prostheses
(dentures, bridge) and last dental
check-up.
Neck

Breast
Pain, lump, nipple discharge, rash,
history of breast disease, any surgery
on the breasts.
Health Promotion: Performs breast
self examination (BSE), including its
frequency and method used, last
mammogram.
Axilla
Tenderness, lump or swelling, rash

Respiratory System
History of lung diseases (asthma,
emphysema, bronchitis, pneumonia,
tuberculosis).
Chest pain with breathing
Wheezing or noisy breathing
Shortness of breath, how much activity
produces shortness of breath
Cough, sputum (color, amount),
hemoptysis (coughing up with blood)
Toxin or pollution exposure
Health Promotion: Last Chest X-ray study

Cardiovascular System
Precordial or retrosternal pain
Palpitations
Cyanosis (bluish discoloration of the skin)
Dyspnea on exertion (e.g. shortness of
breath when walking one flight of stairs,
walking from chair to bath, or just talking)
Orthopnea (difficulty in breathing when
lying down, relieved by upright position)
Paroxysmal nocturnal dyspnea (difficulty
in breathing 2 to 5 hours after going to
sleep during the night).

Nocturia (frequent urination during


the night)
Edema
History of heart murmur
Hypertension, coronary artery
disease, anemia
Health promotion: Date of last ECG
or other heart tests

Peripheral Nervous System


Coldness, numbness and tingling, swelling of
legs (time of day, activity)
Discoloration in hands or feet (bluish red,
pallor, mottling, associated with position,
especially around feet and ankles)
Varicose veins or complications
Intermittent claudication (leg pain on activity
and exercise relieved by rest)
Thrombophlebitis, ulcers
Health Promotion: Does the work involve long
term sitting or standing? Avoid crossing the
legs at the knees. Wear support hose.

Gastrointestinal System
Appetite, food intolerance
Dysphagia (difficulty in swallowing, heartburn,
indigestion, pain associated with eating
Abdominal pain, pyrosis (esophageal and
stomach burning sensation with sour eructation)
Nausea and vomiting, hematemesis (vomiting
blood)
History of abdominal disease (ulcer, liver or
gallbladder, jaundice, appendicitis, colitis)
Flatulence, frequency of bowel movement, stool
characteristics, constipation or diarrhea, black
stools
Rectal bleeding, rectal conditions (hemorrhoids,
fistula)
Health Promotion: Use of antacids or laxatives

Urinary System
Frequency, urgency, nocturia
Dysuria, polyuria, oliguria
Hesitancy or straining, narrowed stream
Urine color (cloudy or presence of hematuria)
Incontinence, history of urinary disease
(kidney disease, kidney stones, urinary tract
infections, prostate enlargement)
Pain in flank, groin, suprapublic region or low
back
Health Promotion: Measures to avoid or treat
urinary tract infections, use of Kegels
exercises after childbirth

Male Genital System


Penis or testicular pain
Sores or lesions, penile discharge, lumps, hernia
Health Promotion: Perform testicular self
examination? How frequently?
Female Genital System
Menstrual history (age at menarche, last
menstrual period, cycle and duration, any
amenorrhea, menorrhagia, premenstrual pain or
dysmenorrheal, intermenstrual spotting)
Vaginal itching, discharge and its characteristics
Age at menopause, menopausal signs and
symptoms, postmenopausal bleeding
Health Promotion: Last gynecologic check up
and last Papanicolaou test

Musculoskeletal System
History of arthritis or gout
In the joints: pain, stiffness, swelling (location,
migratory nature), deformity, limitation of
motion, crepitus (noise with joint motion)
In the muscles: any pain, cramps, weakness,
gait problems, problems with coordinated
activities.
In the back: any pain (location and radiation to
extremities), stiffness, limitation of motion,
history of back pain or disk disease.
Health Promotion: How much walking per day?
What is the effect of limited range of motion on
daily activities such as grooming, feeding,
toileting, dressing? Are any mobility aids used?

Neurologic System
History of seizure disorder, stroke, fainting
blackouts.
In motor function: weakness, tic or tremor,
paralysis or coordination problems.
In sensory function: numbness and tingling
(paresthesia).
In cognitive function: memory disorder
(recent, distant), disorientation
In mental status: any nervousness, mood
change, depression, or any history of mental
health dysfunction or hallucinations.
Health Promotion: Interpersonal relationships
and coping patterns.

Hematologic System
Bleeding tendency of skin or mucous
membranes, excessive bruising
Lymph node swelling
Exposure to toxic agents or radiation
Blood transfusion and reactions
Endocrine System
History of diabetes or diabetic symptoms
(polyuria, polydipsia, polyphagia)
History of thyroid disease, intolerance to heat
and cold, change in skin pigmentation or
texture, excessive sweating, relationship
between appetite and weight, abnormal hair
distribution, nervousness, tremors, need for
hormone therapy.

8. Functional Assessment (Including Activities of


Daily Living)
. Functional assessment measures a persons self
care ability in the areas of general physical health
or absence of illness. This includes the following:
1.Activities of Daily Living (ADLs)
E.g., bathing, dressing, toileting, eating, walking.
2.Instrumental Activities of Daily Living (IADLs) or
those needed for independent living.
E.g., housekeeping, shopping, cooking, doing
laundry, using the telephone, managing
finances.
3.Nutrition
4.Social Relationships and Resources
5.Self Concept and Coping
6.Home Environment

Functional Assessment questions


which should be included in the
standard health history are as
follows:
1.Self esteem, Self concept
Educational attainment and
trainings
Financial status (income)
Religious practices and perception
of personal strengths (value belief
system)

2. Activity/Exercise
Usual daily activities (ask: Tell me how you
spend a typical day?
Ability to perform ADLs: independent or needs
assistance with feeding, bathing, hygiene,
dressing, toileting, bed to chair transfer,
walking, standing, or climbing stairs.
Any use of wheelchair, prostheses or mobility
aids?
Leisure activities enjoyed
Exercise pattern (type, amount per day or
week, method of monitoring the bodys
response to exercise).

3. Sleep and Rest


Sleep patterns
Daytime naps
Any sleep aids used (sleeping pills,
CPAP for sleep apnea/snoring)
4. Nutrition/Elimination
Eating habits and current appetite
Ask: Who buys food and prepares
food?
Are your finances adequate for
food?
Who is present at mealtimes?

Food allergies and intolerance


Daily intake of caffeine (coffee, tea, cola drinks)
Usual pattern of bowel and bladder elimination
Problems with mobility or transfer in toileting,
continence, use of laxatives.
5. Interpersonal Relationship/Resources
Social Role: How would you describe your role
in the family?
How would you say you get along
with the family, friends and, and coworkers?
Support Systems: To whom could you go for
support with a problem at work, with your
health, or a personal problem?

6. Spiritual Resources
Faith: Does religious faith or spirituality
play an important part in your life?
Do you consider yourself to be a
religious or spiritual person?
Influence: How does your religious faith or
spirituality influence the way you think
about your health or the way you care
for yourself?
Community: Are you a part of any religious
or
spiritual
community
or
congregation?
Address: Would you like me to address any
religious or spiritual issues or concerns
with you?

7. Coping and Stress Management


Kinds of stresses in life, especially in the last year,
any change in lifestyle or any current stress.
8. Personal Habits
Tobacco, Alcohol, Street Drugs:
.Tobacco Use
Do you smoke cigarettes?
At what age did you start?
How many packs do you smoke per day?
How many years have you smoked?
Have you ever tried to quit?
How did it go?

Alcohol
Do you drink alcohol?
When was your last drink of alcohol?
How much did you drink that time?
Out of the last 30 days, about how many
days would you say that you drink alcohol?
Have you ever had a drinking problem?
Do you have a history of alcohol treatment?
Do you have a history of family member with
problem drinking?

CAGE
Test
(Ewing,
1984)
Screening
Questionnaire
to
identify
excessive
or
uncontrolled drinking.
C ut down (Have you ever thought that you
should cut down your drinking?)
A nnoyed (Have you ever been annoyed by
criticism of your drinking?)
G uilty (Have you ever felt guilty about your
drinking?)
E ye Opener (Do you drink in the morning?)
If the person answers yes to two or more
CAGE questions, suspect alcohol abuse.

If the person answers no to


drinking alcohol, ask the reason for
this decision (e.g., psychosocial,
legal, health, religion).
Illicit/Street Drugs (Exercise great
caution when asking questions
about use of drugs)
Ask specifically about marijuana,
cocaine,
amphetamines,
and
barbiturates.
Frequency of use and how has

9. Environment/Hazards
Housing and neighborhood
.Safety of area
.Adequate ventilation and
utilities
.Access to transportation
.Involvement in community
services
Hazards in workplace, at home

10.Intimate Pattern: Violence


Begin with open ended questions.
Ask: How are things at home?
Do you feel safe?
These are valuable initial questions,
because some people may not
recognize that they are in abusive
situations or may be reluctant to
admit it due to guilt, fear, shame or
denial.
If the person responds to feeling
unsafe, follow up with close

Ask: Have you ever been emotionally or


physically abused by your partner or someone
important to you?
Within the last year, have you been hit,
slapped, kicked, pushed, or shoved, or
otherwise physically hurt by your partner or
ex-partner?
If yes, by whom?
Number of times?
Does your partner ever force you into having
sexual intercourse?
Are you afraid of your partner or ex-partner?

11.Occupational Health
Ask the patient to describe his or
her job.
Ever worked with any health
hazard
such
as
inhalants,
chemicals?
Wear any protective equipment?
Any work programs in place that
monitor exposure?
Aware of any health problem now
that may be related to work

Perception of Health
Ask: How do you define health?
How do you view your situation
now?
What are your concerns?
What do you think will happen in
the future?
What are your health goals?
What do you expect from nurses
and physicians of other
healthcare providers?