7534783
The Complete Health History
- Biographic Data
- Name, address,
phone number, age,
birth date, birthplace,
gender, marital
partner status, race,
ethnic origin,
occupation, illness or
disability, primary
language
- source of history
- record who
gave the
information.
Judge how
reliable the
informant and
information is
- record who
gave the
information.
Judge how
reliable the
informant and
information is
- source of history
- Name, address,
phone number, age,
birth date, birthplace,
gender, marital
partner status, race,
ethnic origin,
occupation, illness or
disability, primary
language
- Reason for seeking care
- subjective data- symptoms, sign, reason for the visit
- subjective data- symptoms, sign, reason for the visit
- Present health or history of present illness
- Location of the pain i.e. pain behind the eyes
- character or
quality- i.e.)
descriptive terms
such as burning,
sharp, dull..
- quantity or severity- i.e. pain scale 0-10
- timing- onset, duration, frequency
- setting- where was
the person or what
was the person
doing when
symptom started i.e.
chest pain start
when shoveling
snow?
- Aggravating or Relieving Factors- what makes the pain worse i.e. food, medication
- associated factors- primary symptom associated with other factors?
- patient's perception- how symptoms has affected the patient
- patient's perception- how symptoms has affected the patient
- associated factors- primary symptom associated with other factors?
- Aggravating or Relieving Factors- what makes the pain worse i.e. food, medication
- setting- where was
the person or what
was the person
doing when
symptom started i.e.
chest pain start
when shoveling
snow?
- timing- onset, duration, frequency
- quantity or severity- i.e. pain scale 0-10
- character or
quality- i.e.)
descriptive terms
such as burning,
sharp, dull..
- Location of the pain i.e. pain behind the eyes
- past history
- residual effects on the
current health state.
previous illness may also
give clues about how the
person responds to illness
and the significance of the
illness
- childhood illnesses, accidents or
injuries, serious or chronic
illnesses, hospitalization,
operations, obstetric history,
immunizations, last examination
date, allergies. current
medications
- childhood illnesses, accidents or
injuries, serious or chronic
illnesses, hospitalization,
operations, obstetric history,
immunizations, last examination
date, allergies. current
medications
- residual effects on the
current health state.
previous illness may also
give clues about how the
person responds to illness
and the significance of the
illness
- family history
- family history highlights diseases and
conditions for which a particular patient
may be at increased risk
- pedigree/genogram-
graphic family tree that
uses symbols to depict the
gender, relationship, and
age of immediate blood
relatives in at least three
generations
- pedigree/genogram-
graphic family tree that
uses symbols to depict the
gender, relationship, and
age of immediate blood
relatives in at least three
generations
- family history highlights diseases and
conditions for which a particular patient
may be at increased risk
- review of systems
- 1. to evaluate the past
and present health
state of each body
system 2. double check
in case any significant
data were omitted in
the present illness
section 3. evaluate
health promotion
practices
- general overall health state, skin, hair, head, eyes, ears, nose and sinuses, neck, mouth and
throat, breast, axilla, respiratory system, cardiovascular, peripheral vascular,
gastrointestinal, urinary system, male/female genital system, sexual health,
musculoskeletal system, neurological system, hematologic system, endocrine system
- general overall health state, skin, hair, head, eyes, ears, nose and sinuses, neck, mouth and
throat, breast, axilla, respiratory system, cardiovascular, peripheral vascular,
gastrointestinal, urinary system, male/female genital system, sexual health,
musculoskeletal system, neurological system, hematologic system, endocrine system
- 1. to evaluate the past
and present health
state of each body
system 2. double check
in case any significant
data were omitted in
the present illness
section 3. evaluate
health promotion
practices
- functional assessments of activities of daily living (ADLs)
- measures a person's self-care ability in the areas of general physical or absence of illness
- self esteem, self concept, activity/exercise, sleep/rest,
nutrition/elimination, interpersonal
relationships/resources, spiritual resources, coping and
stress management, personal habits, alcohol, illicit or
street drugs, environment/hazards, intimate partner
violence, occupational health
- self esteem, self concept, activity/exercise, sleep/rest,
nutrition/elimination, interpersonal
relationships/resources, spiritual resources, coping and
stress management, personal habits, alcohol, illicit or
street drugs, environment/hazards, intimate partner
violence, occupational health
- measures a person's self-care ability in the areas of general physical or absence of illness
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