Professional Documents
Culture Documents
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)
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.
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.
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).
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
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.
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).
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?
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.
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
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?