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Mapa Mental
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Louise Ma
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Mapa Mental sobre The Complete Health History, creado por Louise Ma el 03/02/2017.
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Louise Ma
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7534783
mind_map
2018-04-06T16:44:28Z
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
Reason for seeking care
source of history
record who
gave the
information.
Judge how
reliable the
informant and
information is
subjective data- symptoms, sign, reason for the
visit
Present health or history of present illness
past history
family history
review of systems
functional assessments of activities of daily living (ADLs)
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
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
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
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
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
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mind_map
2018-04-06T16:44:28Z
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