Module 1: The Complete Health History

The Health History: Adult

1. Biographical data 5. Past health

2. Source of history 6. Family history

3. Reason for seeking care 7. Review of systems

4. Present health or history of present 8. Functional assessment including

illness activities of daily living (ADLs)

Biographical data
1. Name 6. Marital status

2. Address and phone number 7. Race

3. Age and birth date 8. Ethnic origin

4. Birthplace 9. Occupation: usual and present

5. Sex

Source of history
 Record who furnishes information, usually the person, although source may be relative or friend
 Judge reliability of informant and how willing he or she is to communicate
 A reliable person always gives same answers when questions are rephrased or are repeated
later in interview

Reason for seeking care

 Brief spontaneous statement in person’s own words describing reason for visit
 Symptom: subjective sensation person feels from disorder
 What person says is reason for seeking care is recorded and enclosed in
quotation marks to indicate person’s exact words
 Sign: objective abnormality that can be detected on physical examination or in laboratory
reports
Present health or history of present illness
 Location  Setting

 Character or quality  Aggravating or relieving factors

 Quantity or severity  Associated factors

 Timing  Patient’s perception

It may be helpful to organize same question sequence into a mnemonic, PQRSTU, to help remember all
points

 P = Provocative or palliative (What makes symptoms better or worse?)

 Q = Quality or quantity (How does it look, feel, sound?)

 R = Region or radiation (Where is it located?)

 S = Severity scale: 1 to 10 (How bad is it?)

 T = Timing or onset (When, how often, how long?)

 U = Understand patient’s perception of problem

Past Health
 Childhood illnesses  Obstetric history

 Accidents or injuries  Immunizations

 Serious or chronic illnesses  Last examination date

 Hospitalizations  Allergies

 Operations  Current medications

Family history

 Age and health or cause of death of relatives

 Health of close family members
 Family history of various conditions such as heart disease, high blood pressure, stroke, diabetes,
blood disorders, cancer, sickle-cell anemia, arthritis, allergies, obesity, alcoholism, mental illness,
seizure disorder, kidney disease, and tuberculosis
 Family tree (genogram) to show this information clearly and concisely
Review of systems
1. General overall health state 13. Cardiovascular
2. Skin 14. Peripheral vascular
3. Hair 15. Gastrointestinal
4. Head 16. Urinary system
5. Eyes 17. Male genital system
6. Ears 18. Female genital system
7. Nose and Sinuses 19. Sexual health
8. Mouth and Throat 20. Musculoskeletal system
9. Neck 21. Neurologic system
10. Breast 22. Hematologic system
11. Axilla 23. Endocrine system
12. Respiratory system

Functional assessment, including ADLs

 Self-esteem, self-concept
 Activity and exercise
 Sleep and rest
 Nutrition and elimination
 Interpersonal relationships and resources
 Spiritual resources
 Coping and stress management
 Personal habits
 Alcohol
o 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, an Eye opener?
  Illicit or street drugs
 Environment and work hazards
 Intimate partner violence
 Occupational health

Perception of health
Ask 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, physicians, or other health care providers?
Name: Date:

MODULE 1

THE COMPLETE HEALTH HISTORY

Learning Objectives:

The learner will:

 State the purpose of a complete health history.

 Describe the components of a complete health history.
 Perform a complete health history.
 Document a complete health history obtained from a patient.
 Discuss the results of the interview.

Activity 1: Fill in the Blank

Complete the following statements.

1. The purpose of a complete health history is to obtain data.

2. The data when combined with data forms

the data base.

3. The is the one who furnishes the health

information. It could be the patient or the patient’s relative or companion.

4. The should reveal the patient’s responses to his

or her symptoms and what effect the illness has had on the patient’s life.

5. When asking about family history, a family tree or a

can be used to illustrate the information clearly and concisely.

List the categories of information obtained from a health history:

1. 4.

2. 5.

3. 6.
7. 8.

Activity 2. Match the component of the health history with the information
obtained:

Answer Component Information Obtained

Identifying data A. May include medications, allergies,

and habits of smoking and alcohol.

Reliability B. Risk factors

Chief Complaints C. Documents historical presence or

absence of specific illnesses.

Present Illness D. Establishes source of referral

Family History E. Documents health status of blood

relatives

Review of systems F. One or more symptoms or concerns

Health Patterns G. Systematic documentation of

presence or absence of common
symptoms.

Past History H. Varies according to the patient’s

memory, trust, and mood.

Activity 3. Essay

1. Explain why it is important to ask the patient’s functional health patterns when
performing a health history.
Activity 4. Health History

1. Obtain a health history from an individual between 20-45 years old. Use the
form as a guide for your interview.

2. Construct a genogram to illustrate the individual’s family history.