Running head: HEALTH HISTORY 1
Health History Guide
HEALTH HISTORY 2
Date of history
Place of Birth
Source of referral
HEALTH HISTORY 3
Source of history
Chief complaints/reason for visit
Time of onset
Type of onset
Source of relief
Source of aggravation
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
General State of Health:
Childhood Illnesses: (measles, mumps, rubella, whooping cough, chicken pox, scarlet
fever, rheumatic fever, polio)
Adult Illnesses: (HTN, CAD, DM, Lung…)
Accidents and Injuries
Current health status
Current Medications (prescription or OTC)
Screening Tests (PPD, Pap, Mammograms, stools…)
Immunizations (tetanus, pertussis, diphtheria, polio, mumps, measles, rubella, influenza,
Hepatitis B, Flu, Pneumococcal)
HEALTH HISTORY 5
Family history: (Age and health or age and cause of death)
HEALTH HISTORY 6
Review of systems
General: Overall state of health, changes in ADL’s, weight, fatigue, fever, increased
Skin: Rashes, lumps, sores, itching, dryness, color change changes in hair or nails.
NEUROLOGIC: Seizures, headaches, paralysis. Numbness, weakness, syncope, restless,
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.
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)
Other self-care behaviors
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
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?
Daily intake caffeine (coffee, tea, colas)
Number packs per day
Daily use for how many years
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
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
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
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
Highest degree or grade level attained
Judgment of intellect relative to age
Patterns of health care
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
24-Hour Diet Recall;
TIME FOOD EATEN CALORIE AMOUNT
Client’s Height _______________ Weight ______________________
HEALTH HISTORY 14
Whole grains, breads
Vitamin c-rich foods
Other fruits and
Fats and oils
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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