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The Complete Health

The Complete Health History

The Complete Health History (blank)
Subjective data what the person says about himself or herself.
Objective data obtained from the physical examination and laboratory studies to form the data base
The health history provides a complete picture of the person's past and present health status (blank)
The Complete Health History Includes: A description of the individual as a whole and how the person interacts with the environment, Health strengths and coping skills , Recognizes and affirms what the person is doing right – how they are staying well , screening tool for abnormal symptoms, he
Ill person Detailed and chronologic record of the health problem,
Most health histories contain information about seven categories: Biographical data, Reason for seeking care, Present health or history of present illness, Past history, Family history, Review of systems, Functional assessment or activities of daily living (ADLs)
Biographical Data Name, Address and phone number, Age and birth date, Birthplace, Gender, marital status, race, ethnic origin, Occupation, usual and present, Source of History, Record who furnishes the information, Judge the reliability of the informant, Note any special
Reason for Seeking Care This is a brief spontaneous statement in the person's own words that describes the reason for the visit – now, Whatever the person says is the reason for seeking care is recorded, enclosed in quotation marks to indicate the person's exact words
It states one (possibly two) symptoms or signs and their duration (blank)
A symptom is a subjective sensation that the person feels from the disorder.
A sign is an objective abnormality that you as the examiner could detect on physical examination or in laboratory reports
Present Health or History of Present Illness (HPI) Well person: a short statement about the general state of health, Ill person: a chronologic record of the reason for seeking care, Document the time the symptom first started until present time Isolate each reason for care (sign or symptom) identif
Eight Critical Characteristics of a Symptom: Location: Be specific with anatomical location
Eight Critical Characteristics of a Symptom: Character or Quality: 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 vomitus look like coffee grounds?
Eight Critical Characteristics of a Symptom: Quantity or Severity: Attempt to quantify the sign or symptom such as "profuse menstrual flow soaking five pads per hour." With pain, avoid adjectives and ask how it affects daily activities.
Eight Critical Characteristics of a Symptom: Timing: Onset, Duration, Frequency
Eight Critical Characteristics of a Symptom: Setting: Where was the person or what was the person doing when the symptom started? What brings it on?
Eight Critical Characteristics of a Symptom: Aggravating or Relieving Factors: What makes the pain worse? What relieves it , What is the effect of any treatment?
Eight Critical Characteristics of a Symptom: Associated Factors: Is this primary symptom associated with any others , Review the body system related to this symptom now rather than wait for the review of systems.
Eight Critical Characteristics of a Symptom: Patient's Perception: Find out the meaning of the symptom by asking how it affects daily activities. Also ask directly, "What do you think it means?"
PQRSTU P: Provocative or Palliative. What brings it on? What were you doing when you first noticed it? What makes it better? Worse?
PQRSTU Q: Quality or Quantity. How does it look, feel, sound? How intense/severe is it?
PQRSTU R: Region or Radiation. Where is it? Does it spread anywhere?
PQRSTU S: Severity Scale. How bad is it (on a scale of 1 to 10)? Is it getting better, worse, staying the same?
PQRSTU T: Timing. Onset—Exactly when did it first occur? Duration—How long did it last? Frequency—How often does it occur?
PQRSTU U: Understand Patient's Perception of the problem. What do you think it means?
Past health is important: Residual effects on the current health state, Previous experience with illness gives clues , How the person responds to illness, The significance of illness
Childhood Illnesses: Measles, mumps, polio, rubella, chicken pox, pertussis, and strep throat. Avoid recording "usual childhood illnesses" Ask about serious illnesses that may have sequelae for the person in later years (e.g., rheumatic fever, scarlet fever, and poliomyelit
Accidents or Injuries Auto accidents, fractures, penetrating wounds, head injuries (especially if associated with unconsciousness), and burns
Serious or Chronic Illnesses Diabetes, hypertension, heart disease, sickle-cell anemia, cancer, and seizure disorder
Hospitalizations Cause, name of hospital, how the condition was treated, how long the person was hospitalized, and name of the physician
Operations Type of surgery, date, name of the surgeon, name of hospital, and how the person recovered.
Obstetric History Number of pregnancies (gravidity), number of deliveries in which the fetus reached full term, number of preterm pregnancies, number of incomplete pregnancies (spontaneous or induced AB), and number of children living (living). This is recorded: Gravida
Immunizations: Measles-mumps-rubella (MMR), polio (IPV), diphtheria-pertussis-tetanus (DPT), Hepatitis A & B, Haemophilus influenzae type b (Hib), pneumococcal, HPV vaccine. Note the date of the last tetanus immunization, tuberculosis skin test, pneumococcal and last
Last Examination Date Physical, dental, vision, hearing, electrocardiogram, chest x-ray examinations.
Allergies Note both the allergen (medication, food, or contact agent, such as fabric or environmental agent) and the reaction (rash, itching, runny nose, watery eyes, difficulty breathing). With a drug, this symptom should not be a side effect but a true allergic
Current Medications Note all prescription and over-the-counter medications. Ask specifically about vitamins, birth control pills, aspirin, and antacids
Document: Name (generic or trade name), dose, schedule & ask: "How often do you take it each day?“ "What is it for?" "How long have you been taking it?"
Family History The age and health or the age and cause of death of blood relatives, such as parents, grandparents, and siblings, Specifically ask for any family history of heart disease, high blood pressure, stroke, diabetes, blood disorders, cancer, sickle-cell anemia
The purposes of this section are To evaluate the past and present health state of each body system, To double-check in case any significant data were omitted in the present illness section, To evaluate health promotion practices
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, hives), pigment or color change, change in mole, excessive dryness or moisture, pruritus, excessive bruising, rash or lesion
Hair Recent loss, change in texture. Nails: change in shape, color, or brittleness
Hair Health Promotion Amount of sun exposure; method of self-care for skin and hair
Head Any unusually frequent or severe headache, any head injury, dizziness (syncope) or vertigo
Eyes Difficulty with vision (decreased acuity, blurring, blind spots), eye pain, diplopia (double vision), redness or swelling, watering or discharge, glaucoma or cataracts
Eyes Health Promotion Wears glasses or contacts; last vision check or glaucoma test; and how coping with loss of vision if any
Ears Earaches, infections, discharge and its characteristics, tinnitus or vertigo.
Ears Health Promotion Hearing loss, hearing aid use, how loss affects the daily life, any
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 sense of smell
Mouth and Throat Mouth pain, frequent sore throat, bleeding gums, toothache, lesion in mouth or tongue, dysphagia, hoarseness or voice change, tonsillectomy, altered taste.
Mouth and Throat Health Promotion Pattern of daily dental care, use of prostheses (dentures, bridge), and last dental checkup
Neck Pain, limitation of motion, lumps or swelling, enlarged or tender nodes, goiter
Breast Pain, lump, nipple discharge, rash, history of breast disease, any surgery on the breasts
Breast Health Promotion Performs breast self-examination, 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, tox
Respiratory System Health Promotion Last chest x-ray study
Cardiovascular Precordial or retrosternal pain, palpitation, cyanosis, dyspnea on exertion, orthopnea, paroxysmal nocturnal dyspnea, nocturia, edema, history of heart murmur, hypertension, coronary artery disease, anemia
Cardiovascular Health Promotion Date of last ECG or other heart test
Peripheral Vascular Coldness, numbness and tingling, swelling of legs (time of day, activity), discoloration in hands or feet, varicose veins or complications, intermittent claudication, thrombophlebitis, ulcers
Peripheral Vascular Health Promotion Does the work involve long-term sitting or standing? Avoid crossing legs at the knees. Wear support hose.
Gastrointestinal Appetite, food intolerance, dysphagia, heartburn, indigestion, pain (associated with eating), other abdominal pain, pyrosis, nausea and vomiting (character), vomiting blood, history of abdominal disease, flatulence, frequency of bowel movement, any recent
Gastrointestinal Health Promotion Use of antacids or laxatives, (Alternatively, diet history and substance habits can be placed here.)
Urinary System Frequency, urgency, nocturia, dysuria, polyuria or oliguria, hesitancy or straining, narrowed stream, urine color, incontinence, history of urinary disease, pain in flank, groin, suprapubic region, or low back
Urinary System Health Promotion Measures to avoid or treat urinary tract infections, use of Kegel exercises after childbirth
Male Genital System Penis or testicular pain, sores or lesions, penile discharge, lumps, hernia
Male Genital System Health Promotion Perform testicular self-examination? How frequently?
Female Genital System Menstrual history (age at menarche, last menstrual period, cycle and duration, any amenorrhea or menorrhagia, premenstrual pain or dysmenorrhea, intermenstrual spotting), vaginal itching, discharge and its characteristics, age at menopause, menopausal sig
Female Genital System Health Promotion Last gynecologic checkup and last Papanicolaou test
Sexual Health Presently in a relationship involving intercourse? Are the aspects of sex satisfactory to the patient and partner? Any dyspareunia (for female), any changes in erection or ejaculation (for male), and use of contraceptive? Is the contraceptive method sat
Musculoskeletal System History of arthritis or gout. In the joints: pain, stiffness, swelling (location, migratory nature), deformity, limitation of motion, noise with joint motion?
Musculoskeletal System Health Promotion (blank)
How much walking per day? What is the effect of limited range of motion on daily activities, such as on grooming, feeding, toileting, dressing? Are any mobility aids used? (blank)
Neurologic System History of seizure disorder, stroke, fainting, blackouts.
Motor function weakness, tic or tremor, paralysis, or coordination problems
Sensory function: numbness and tingling (paresthesia).
Cognitive function: memory disorder (recent or distant, disorientation)
Mental status: any nervousness, mood change, depression, or any history of mental health dysfunction or hallucinations, Health Promotion
Alternatively, data about interpersonal relationships, coping patterns placed here (blank)
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), 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, a
Self-Esteem, Self-Concept Education (last grade completed, other significant training, Financial status (income adequate for lifestyle and/or health concerns), Value-belief system (religious practices and perception of personal strengths)
Activity/Exercise A daily profile reflecting usual daily activities, Record leisure activities enjoyed and exercise pattern (type, amount per day or week, method of warm-up session, method of monitoring the body's response to exercise)
Sleep/Rest Sleep patterns, daytime naps, any sleep aids used
Nutrition/Elimination Record the diet by a recall of all food and beverages taken over the last 24 hours "Is that menu typical of most days?" Indicate any food allergy or intolerance, Record daily intake of caffeine (coffee, tea, cola drinks), Ask about usual pattern of bowe
Interpersonal Relationships/Resources. Social roles: "How would you describe your role in the family?" "How would you say you get along with family, friends, and co-workers?" Ask about support systems composed of family and significant others, Include contact with spouse, siblings, parents,
Spiritual Resources Faith, influence, community, and address (FICA) questions to incorporate the person's spiritual values into the health history
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?"
Coping and Stress Management Kinds of stresses in life, especially in the last year, Any change in lifestyle or any current stress, methods tried to relieve stress, and if these have been helpful
Tobacco, alcohol, street drugs: Record the number of packs smoked per day (PPD) and duration, e.g., 1 PPD × 5 years , Then ask, "Have you ever tried to quit?" and "How did it go?" to introduce plans about smoking cessation
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 drank alcohol?" "Have you ever had a drinking problem?"
Alcohol CAGE Questionnaire
Cut down, Annoyed, Guilty, and Eye-opener (CAGE) test Have you ever thought you should Cut down your drinking? Have you ever been Annoyed by criticism of your drinking? Have you ever felt Guilty about your drinking? Do you drink in the morning? (i.e., an Eye opener?)
Street Drugs Marijuana, cocaine, crack cocaine, amphetamines, and barbiturates. Indicate frequency of use and how has usage affected work or family
Environment/Hazards Housing and neighborhood (living alone, knowledge of neighbors), safety of area, adequate heat and utilities, access to transportation, and involvement in community services. Note environmental health, including hazards in workplace, hazards at home, use
Intimate Partner Violence (IPV) Begin with open-ended questions: "How are things at home?" and "Do you feel safe?" "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 sh
Occupational Health Ask the person to describe his or her job. Asbestos, inhalants, chemicals, repetitive motion? Wear any protective equipment? Aware of any health problems now that may be related to work exposure? Note the timing of the reason for seeking care, and whet
Perception of Health Ask the person questions such as: "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 us as nurses, physicia
Children and Adolescents The health history is adapted to include information specific for the age and developmental stage of the child, The developmental history and nutritional data are listed as separate sections because of their importance for current health
The Older Adult These questions address ways in which the ADLs may have been affected by normal aging processes or by the effects of chronic illness or disability , Recognize positive health measures
Reason for Seeking Care Time , These people come for care only when something is blatantly wrong , Chronic problems, The final statement should be the person's reason for seeking care, not your assumption of what the problem is
General Health - Health state in the last 5 years
Accidents or Injuries, serious or Chronic Illnesses, Hospitalizations, Operations Lack of chronologic order (reorder the events later), Lengthy responses
Last Examination Most recent mammography, proctoscopy, and tonometry
Obstetric Status It is not necessary to collect a detailed account of each pregnancy and delivery if the woman has passed menopause and has no gynecologic symptoms, Record the number of pregnancies and the health of each newborn
Current Medications Record the name, purpose, and daily schedule. , Does the person have a system to remember to take the medicine? Does medicine seem to work? Are there any side effects? If so, does the person feel like skipping medicine because of them?
Also consider the following issues: Is cost a problem? Is traveling to the pharmacy to refill a prescription a problem? Is the person taking any over-the-counter medications? Has the person ever shared medications with neighbors or friends? (blank)
***Remember that these are additional items to question for the older adult*** (blank)
General- Present weight and what the person would like to weigh (gives idea of body image)
Skin - Change in sensation to pain, heat, or cold
Eyes - Use of bifocal glasses, any trouble adjusting to far vision (problems with stairs)
Ears - Increased sensitivity to background noise and whether conversation sounds garbled or distorted.
Mouth Use of dentures, when the person wears them, method of cleaning, any difficulty wearing the dentures, cracks at corners of the mouth.
Respiratory System Shortness of breath and level of activity that produces it.
Cardiovascular System If chest pain occurs, the person may not feel it as intensely as a younger person. Instead, the older adult may feel dyspnea on exertion.
Peripheral Vascular System Wears constrictive clothing, garters, or rolls stockings at knees. Any color change at feet or ankles.
Urinary System Urinary retention, incomplete emptying, straining to urinate, change in force of stream
Sexual Health Ask about any changes in sexual relationship the person has experienced (vaginal dryness or pain with intercourse). Note whether aspects of sex are satisfactory and whether adequate privacy exists for sexual relationship
Musculoskeletal System Gait change (balance, weakness, difficulty with steps, fear of falling), use of any assistive device (cane, walker). Any joint stiffness? During what part of the day does the stiffness occur? Does pain or stiffness occur with activity or rest?
Neurologic System Any problem with memory (recent or remote) or disorientation (time of day, in what settings)?
Functional assessment measures how a person manages day-to-day activities. The meaning of health becomes those activities that they can or cannot do. The impact of a disease on their daily activities and overall quality of life (called the disease burden) is more important to older people than the actual disease diagnosis or pa
Self-Concept, Self-Esteem lack of education
Occupation Past positions, volunteer activities, and community activities. If the person is retired, how has he or she adjusted to the change in role? Finances?
Sleep and Rest Usual sleep pattern: Feel rested during the day? Is energy sufficient to carry out daily activities? Need naps? Is there a problem with night wakenings (nocturia, shortness of breath, light sleep, insomnia [difficulty falling asleep, awakening during night, early morning wa
Older Adult - Functional Assessment (Including Activities of Daily Living) (blank)
Nutrition/elimination Record a 24-hour recall. Is this typical of most days? , What are the meal patterns? , Are there three full meals or five to six smaller meals per day? , How many convenience foods and soft foods are used? Who prepares meals? Eat alone? Who shops for foo
Interpersonal Relationships/Resources Who else is at home with you? Live alone? Is this satisfactory? Have a pet? How close are family or friends? How often do you see family or friends? If infrequent, do you experience this as a loss?
Interpersonal Relationships/Resources Do you live with family, such as a spouse, children, or a sibling? Is this a satisfactory arrangement? What is the role in family for preparation of meals, housework, and other activities? Are there any conflicts?
Interpersonal Relationships/Resources On whom do you depend for emotional support? For help with problems? Who meets affection needs?
Coping and Stress Management Has there been a recent change in lifestyle, such as loss of occupation, spouse, friends, move from home, illness of self or family member, or has income been decreased? How dealing with stress? If a loved one has died, how responding to the loss? "How do
Home safety: one floor or are there stairs, state of repair, is money adequate to maintain home, exits for fire, heating and utilities adequate, how long in the present home?
Transportation: own automobile, last driver's test, consider self a safe driver, income adequate for maintenance, public transportation access, receive drives from community resources, friends?
Neighborhood: secure in personal safety at day or night; danger of loss of possessions; amount of noise and pollution; access to family and friends, grocery store, drug store, laundry, church, temple, mosque, health care facilities?
Created by: holtanmir